Naming and Location Guide

Document TypeName ExampleRec’d DateExp DateAttachment Location
Request to Credential (RTC)Johnson RTC, pg 4 & 5n/an/aAffiliation Form / Corresponding Client
ApplicationJohnson Apn/an/aCred / Verif Form
Client Application DocumentsJohnson MGH documents 14XAffiliation Form / Corresponding Client
Client ReleaseJohnson MGH Release 14XAffiliation Form / Corresponding Client
Client Privilege ListJohnson MGH Priv 14XAffiliation Form / Corresponding Client
Client Criminal Background CheckJohnson MGH CBCn/an/aAffiliation Form / Corresponding Client
Client Drug ScreenJohnson MGH Drug Screenn/an/aAffiliation Form / Corresponding Client
Education VerificationJohnson NSCn/a n/a Education Form / on Medical School or Masters Degree
Johnson AMA n/a n/a
Johnson AOA n/a n/a
Certificates of InsuranceJohnson COI 15XInsurance Form / Corresponding insurance entry
Malpractice History (Not a COI)Johnson Malp Hx MHA 14XInsurance Form / Corresponding insurance entry
License VerificationSystem Names for you, or Johnson Lic Verif OH 15XLicense Form / Corresponding state license entry
DEA CopyJohnson DEA 16XLicense Form / DEA entry
Board Certification VerificationJohnson BC Verif 18 X
Specialties/Baords Form
Johnson AMA n/an/a
Johnson AOAn/an/a
Affiliation Verification (FAVQ & Prov Eval or letter)Johnson Aff MGH 14XAffiliation Form / Corresponding hospital/employer
Facility Affiliation Verification (FAVQ ‐ 2 pages)Johnson FAVQ MGH 14XAffiliation Form / Corresponding hospital/employer
Provider Evaluation (Prov Eval ‐ 3 pages)Johnson Prov Eval MGH 14XAffiliation Form / Corresponding hospital/employer
Reference QuestionnaireJohnson Ref Smith 14XAffiliation Form / Corresponding reference
Residency Verification QuestionnaireJohnson Res UofM Hospn/an/aEducation Form / Corresponding residency entry
Fellowship Verification QuestionnaireJohnson Fellow Mercy Hospn/an/aEducation Form / Corresponding fellowship entry