Form 0917-0009 Cred by Proxy

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Details - MD-App

Dione Harjo - Credentialing by Proxy Intake
Instructions
Form Approved
OMB XXXX-XXXX
Expires XX/XX/XXXX

Welcome to Indian Health Service
The Federal Health Program for American Indians/Alaska Natives

Our Mission: The overall mission of the Indian Health Service is to raise the physical, mental, and social and
spiritual health of American Indians and Alaska Natives (AI/AN) to the highest level.
Our Goal: To ensure that comprehensive, culturally acceptable personal and public health services are
available and accessible to American Indians & Alaska Native people.

Information and Tips for Completing the Electronic Credentialing by Proxy Intake
Form
INSTRUCTIONS: Enter all pertinent information, as applicable. Fill out all required sections and
fields that are marked in Red; these are mandatory and must be completed to submit the
application. At any point, the electronic intake form may be saved by clicking Save and completed
at a later time. The blue toolbar at the top right provides additional help.
Packet Documents included on the previous home screen are MANDATORY. These must be
viewed and/or filled out and uploaded into the Files section on this application. Please note
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that any documents that require electronic signature are found at the end of the application.
The Head Icon at the top right allows the applicant to change or reset the password and
authorize account access to a delegate.
Help Icon provides support if technical difficulties are encountered.
Return To Application after submitting the application, where the completed intake form and
supporting documents may be viewed, downloaded, or printed.
UPLOADING DOCUMENTS: Completed documents and forms must be uploaded in the Files section
of this application. Please contact the Medical Staff Credentialing Coordinator for other delivery
methods if technical difficulties are encountered.
ATTENTION: Misrepresentations, inaccuracies, or falsification of any information may be grounds
for denial or termination of medical staff appointment and/or associated clinical privileges, and
may be subject to the reporting requirements of the National Practitioner Data Bank (NPDB), and
state and federal licensing boards.
INCOMPLETE ELECTRONIC INTAKE FORMS & MISSING DOCUMENTS: Intake forms with incomplete
information or missing documents will be returned to the applicant and may delay the
credentialing by proxy process.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0917-0009. The time required to complete this
information collection is estimated to average 15 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, to review and
complete the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: Indian Health Services,
OMS/DRPC, 5600 Fishers Lane, 09E70, Rockville, MD 20857, Attention: Information Collections
Clearance Officer.

Personal Information
Enter the requested information.
Mandatory fields are in Red. Click Edit to modify this section and Save to save the information entered.
Last Name

Harjo
First Name

Dione
Middle Name
Suffix
Degree
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Birth Date
NPI
SSN
Birth Place
Gender
Cell
E-Mail

[email protected]
✏ Edit

Education
List all institutions and colleges where education and training was received. This includes all
undergraduate education, graduate education, residencies, and fellowships. Also list all colleges where
a degree was transferred from or not obtained. If the exact start or end date is unknown, please ensure
that the month and year are correct.
New Education

+ Add

Licenses/Credentials
Enter the information for one active state license.
New Licenses/Credentials

+ Add

Board Certifications
List all board certifications currently held, if applicable.
New Board Certifications

+ Add

Files
Upload the following required document. Forms that require signature are either housed on the login
screen, at the end of the application for electronic signature, or will be emailed to you.
1. Completed Statement of Understanding & Release Form (MUST be uploaded to submit
application.)
To upload a digital document (pdf, jpg, etc):
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1. Select Add
2. Select a File Type
3. Enter a Description (Optional)
4. Click on Click To Upload to browse for the file
5. Click Save to complete the upload
If unable to perform a document upload, please contact MD-App Support at 1-800-736-7276 or the
Medical Staff Office.
New Files

+ Add

Privileges
Review and request any privileges by clicking on the checkbox. If applicable, please review the core
privileges and uncheck any core privileges for which you do not have current competency to perform.

Submit Information
Final Steps:
1. Click Submit Application. (Once the application has been submitted, you may go back to edit your
data by clicking Unsubmit on the main login page. You may also print the application by clicking
View Application.)
2. On the Electronic Signature page enter your complete and legal name, check the box indicating
that you have read and agree to be bound by the Applicant’s Certification Statement, and that to
the best of your knowledge, all information provided on the application is true and accurate, and
that no material or facts which would render the statement false, fictitious, or fraudulent is
omitted.

The application is incomplete
Submit Application

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