New Clinical Provider Submission Form

This form is currently unavailable. If you need to submit a new clinical provider, please email the Insurance Services Team at:

University of Florida: ufisosip@mail.ufl.edu

Florida State University: fsuisosip@mail.ufl.edu

Florida International University: fiuisosip@mail.ufl.edu

Florida Atlantic University: fauisosip@mail.ufl.edu

University of Central Florida: ucfisosip@mail.ufl.edu

Or call 352.273.7006 and ask to speak with Insurance Services.

Requests to ADD NEW CLINICAL PROVIDERS are to be completed and submitted ONLY by a clinical unit’s designated HR Representative, Division Administrator, Chair, Dean or their designated delegates.  The information requested below is for 1004.24 FBOG HEIC and self-insurance privileged and confidential underwriting purposes and does not meet participants’ independent credentialing or other required hiring background, screening, and/or onboarding processes.

If you need to add more than 10 new providers, STOP .. please do not use this process; rather, call your SIP Insurance Services team directly at the following phone # for assistance: 352-273-7006, or 844- MY FL SIP.

PLEASE NOTE:

• “Providers” (employees or volunteers) are those who deliver professional healthcare services on behalf of the university or SIP protected hospital/entity.
• Click on the following link for FMMJUA Specialty Descriptions to help complete the below questionnaire: FMMJUA Specialty Descriptions 
• Professional Liability Questionnaires (PLQ)** are required for all new hires or volunteers with clinical exposure, or for existing employees or volunteers with newly added clinical exposures, practicing under the following license types: MD, DO, DMD, DPM, PhD, PsyD, PharmD, and are optional (department/service decision) for DDS, DVM, PA, AA, LSW, LBSW, LMSW, LCSW, LMHC, PLC, ARNP, CNM, CM, and CRNA.  Please be sure to attach the required PLQ, as well as the provider’s CV and Letter of Offer, if applicable and available, to this submission. ** If needed, the PLQ template can be found here: Coverage Forms – Self-Insurance Programs Self-Insurance Programs

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