Texas Credentialing Application Checklist
|
|
- Kristina Lloyd
- 6 years ago
- Views:
Transcription
1 APPLICANT NAME: Texas Credentialing Application Checklist TYPE OF DENTIST: In order to facilitate a prompt credentialing process, please complete every item on this application. Please, DO NOT write, See CV or Refer to CV in place of completing the information reuested. Please enclose copies of the documentation listed below, and sign and date the Attestation AcknowledgementsInformation Release consent page. Your application will be evaluated and a determination will be made within 90 days of MCNA's receipt of a COMPLETE application. Thank you for your assistance! Check the box if enclosed: Current State LicenseRegistration Certificate (cannot be less than 30 days prior to the expiration date. A website printout from the Texas State Board of Dental Examiners is not acceptable) Current DEA, CDS Certificate (if applicable) (cannot be less than 30 days prior to the expiration date) Current Professional Liability Insurance Certificate face sheet (cannot be less than 30 days prior to the expiration date) Curriculum VitaeResume outlining history since graduation from dental school, dates in monthyear format (gaps over 6 months reuire an explanation) Copy of Professional Education School Diploma (dental school) Residency Certificate Board Certification or evidence of Board status (if applicable) Additional locations information sheet; enclosed CLIA Certificate or Waiver (as applicable) W9 Form For Plan Use only - To be completed by MCNA Dental Plans Provider Relations Representative Contract(s) attached Provider Site Audit Tool attached Application information and supporting documentation has been reviewed All information meets Plan criteria and documentation is current and complete Office SpecialtyFacility ID if office is existing facility Date Received from Provider Name & Signature of Representative Submitting Information Date Submitted to Credentialing Mail the application and all documentation to: MCNA DENTAL - ATTN: CREDENTIALING DEPARTMENT 200 W CYPRESS CREEK RD., SUITE 500 FT. LAUDERDALE, FL You may also your application to provider_enrollment@mcna.net or fax to Page 1 of 6
2 TEXAS PROVIDER CREDENTIALING APPLICATION Please type or print. Complete ALL sections. Incomplete applications will not be processed. DATE: PLEASE CHECK ALL THAT APPLY o DDS o DMD o OTHER o GENERAL DENTIST o CERTIFIED MAIN DENTAL HOME PROVIDER I. Personal Information: o SPECIALIST, TYPE: Last Name, (Sr. Jr., III, etc) First Name Middle Initial - - Male Female (circle one) SSN Date of Birth Gender For EEOC Compliance Reuirements Only, Please Indicate the Following: Caucasian African American Hispanic Asian American Indian or Alaskan Native Other II. OfficePractice Information: (Attach additional sheets for multiple office locations). Apply with active, operational offices ONLY Name of Primary Practice Primary Office Address City State Zip Code County Office Phone Office Fax Alternate Number Practice Type: Solo Group CountyFQHC Multi-Specialty Group Mobile Unit Single Specialty Group Indian Hlth Svcs If group, please list other members in the practice and their specialty: - Tax ID Number Office NPI# Office TPI # Office MedicaidMedicare # Office ManagerContact Owner Year Established Dental Hygienist (list name(s) and license # attach separate sheet as needed): BillingRemit Name and Address (if different from above) City State Zip Code County Billing Phone Billing Fax Office Patient Base (panel size) Languages Spoken in office: Age Range: from to Office Hours: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Does your office: X-Ray Machines How many Have a Computer System Hardware Software Have a Recall System Mail Phone Call Pre-Appointment Mail Phone Employ Allied Health Professionals Clerical Assistant Lab Technician Other Page 2 of 6
3 Make Provisions for Emergency Coverage With Whom? Phone # Have the Capability for Electronic Billing Meet ADA Accessibility Standards Utilize: Nitrous Oxide Gen Anesthesia Panoramic Have Answering Service Provide Child Services Does This Office Routinely Provide: A. Simple Extractions E. Pediatric Care B. Oral Surgery: F. Full Dentures a. Soft Tissue impaction G. Orthodontics b. Partial bony impaction H. HIV Positive AIDS Patients c. Full bony impaction I. Hepatitis B Carrier Patients C. Endodontic: J. Tuberculosis Positive Patients a. Anterior & Bicuspid K. HandicappedDisabled Patients b. Molar D. Refer to Specialty Care Providers Does your office comply with OSHACDC blood borne pathogen standards in infection control and barrier techniues? Are all your high speed air driven hand pieces, prophy angles and all other metal instruments Autoclaved (heat sterilized) after each patient and do you keep a log? Does your office follow OSHA guidelines with respect to bio-hazardous wastes? Does your office see Medicaid Patients? Does your office see CHIP Kids? III. Dental Education: (gaps over 6 months reuire an explanation) Name of Dental School Completed AddressCityStateZip Degree Awarded Dates Attended (from-to) (MonthYear) Name of Internship Program (if applicable) Completed AddressCityStateZip Degree Awarded Dates Attended (from-to) (MonthYear) i. ResidencyFellowship: Specialty: Graduate Institution: Graduation Date Degree CityState ii. Board Certification: Name of Certifying Board if you are NOT certified Are you Board Eligible? Certification Date(s) Page 3 of 6
4 IV. Hospital Privileges: (if applicable) Hospital AddressCityCounty Hospital AddressCityCounty V. Personal Licensure & Liability Insurance Information: Dental License Number: State: Expiration Date: Dental License Number: State: Expiration Date: DEA License Number: State: Expiration Date: Anesthesia Permit Level(s): NPI Number: Texas Provider Identifier (TPI) Number: Are you EPSDT Certified in Texas? Do you presently carry malpractice insurance? (Please Provide Information For All Malpractice Cases Occurring in Previous 5 yrs. Attach Additional Sheets as Necessary) Name of Insurance Company: Policy #: Coverage Amount per OccurrenceAggregate: Policy Dates: Occurrences: Claim(s) Paid: Dates Paid: VI. Professional References: (List three peers who have direct knowledge of your clinical abilities and are either board certified or have been in practice for more than 5 years.) Name AddressCityStateZip Phone Name AddressCityStateZip Phone Name AddressCityStateZip Phone VII. Work History: (Chronologically, list all positions in the last 5 years on this form. Your CV should list all history since Dental School in month and year format. Gaps over 6 months reuire an explanation.) Current Employer: Name & Address From To Present Former Employer: Name & Address From To Former Employer: Name & Address From To Former Employer: Name & Address From To Former Employer: Name & Address From To Page 4 of 6
5 VIII. Professional Questionnaire: (Please Provide an Explanation for Any YES Responses on a Separate Page) 1. Has your Dental License, DEA License, or any applicable narcotic registration in any jurisdiction ever been denied, limited, reprimanded, sanctioned, suspended, revoked, not renewed, subject to probationary conditions, received any administrative complaint or concerns OR is any such action pending? 2. Have your privileges at any hospital, dental organization or other health care setting ever been suspended, revoked, voluntarily surrendered, denied, reduced, restricted, not renewed or has probation ever been invoked? 3. Have you been denied participation, terminated, suspended, fined or otherwise sanctioned or restricted by MedicareMedicaid, or any other private or public payer, or is any such action pending? 4. Has your professional liability insurance ever been terminated, restricted, special rated, have you been denied professional liability insurance or has your policy ever been cancelled? 5. Has any judgment or settlements been made against you in professional liability cases or are there any filed and served professional liability lawsuits against you pending? 6. Have you ever received sanctions from a regulatory agency (e.g., OFAC, SAM, OIG, etc.?) 7. Has any information on you ever been reported to the National Practitioner Data Bank? 8. Do you have any mental or physical conditions impacting your ability to perform the essential functions of the position for which you are applying with or without accommodation? (ADA Act) 9. Do you currently have or have you had a chemical dependencysubstance abuse problem, treated or untreated which may impact your ability to practice? 10. Within the last five years have you been reprimanded or disciplined in any manner by any State Licensing Authority or other professional board or peer review committee for conduct related to the use of alcohol or use of any illicit drug? 11. Have you ever been convicted of a felony, misdemeanor or been named as a defendant in any criminal case or is any such action pending? Page 5 of 6
6 IX. Attestation AcknowledgementsInformation Release Authorization: I hereby give consent to MCNA Dental Plans to reuest information regarding my professional credentials and ualifications including but not limited to those information listed above, from educational facilities, hospital(s) in which I currently have or formerly had staff privileges, professional certification boards, state regulatory and licensing departments, professional liability insurance carriers, other professional monitoring entities, present and past employers, the National Practitioner Data Bank and all other authorities with information regarding me. The information reuested may include otherwise privileged or confidential material relative to my professional ualifications, credentials, claims history, clinical andor professional competence, character, ethics, or any other matter applicable to the credentialing procedure as determined by MCNA. I release and hold harmless MCNA and any of its respective officers, directors, representatives, employees, agents and affiliated entities from any and all liability for any damages, costs and expenses which may result from the gathering or use of the information gathered during the credentialing process providing such release of information is done in good faith and without malice. I agree that the photocopy or facsimile of this release with my signature may be accepted by any person or entity from which such information is sought with the same authority as the original and I specifically waive written notice from any such entities or individuals who may provide information based upon this authorized reuest. I understand that I have the right to obtain the status and to review and correct erroneous information obtained by MCNA to evaluate my credentialing application at any time after submitting my application. This includes information obtained from primary source (e.g., malpractice insurance carriers, state licensing boards, NPDB, etc.) The review must take place within 6 months of the date on this application. Any corrections must be made in writing within 30 days of the review. This does not reuire MCNA to allow me to review references or recommendations or other information that is peer review protected. I understand and agree that I, as an applicant, have the burden of producing adeuate information for proper evaluation of any professional competence, character, ethics and other ualifications and for resolving doubt about such ualifications. I hereby affirm that the information submitted in this application and any addenda thereto is true to the best of my knowledge and belief and is furnished in good faith. I understand that willful falsification, significant omissions or willful misrepresentations may result in the rejection of my application by MCNA, termination of my current participation, employment, privileges and provider agreement with the MCNA Network. I understand that if my application is rejected for reasons relating to my professional conduct or competence, MCNA may report the rejection to the appropriate state licensing board and or NPDB as reuired. I understand that this application does not entitle me to participation in MCNA s Network and I agree that neither MCNA nor its representatives or any individuals or entities providing information to MCNA in good faith shall be liable for any act or omission related to the evaluation or verification of the information contained in this application. I further agree to notify MCNA in writing within 10 days of receiving any written or oral notice of any adverse action, including without limitation, any filed, served malpractice suit or arbitration action; any adverse action by the Dental Board taken or pending, including but not limited to, any accusation filed, temporary restraining order or interim suspension order sought or obtained; public letter or reprimand, public reprove, and any formal restrictions, probation, suspension or revocation of licensure; any adverse action taken by any Health Care Organization, which has resulted in the filing of a report with the Dental Board or a report with the National Practitioner Data Bank; any revocation of DEA licensure; a conviction of any felony or a misdemeanor of moral turpitude; any action against any certification under the MedicareMedicaid programs; or any cancellation, nonrenewal or material reduction in dental liability insurance policy coverage. Information reuested in this application that is not publicly available will be treated as confidential by MCNA. My Signature hereby attests to the completeness and correctness of the information in this application and authorizes the verification of the information I have provided. Signature of Dentist: Today s Date: Print Name of Dentist: Page 6 of 6
MEDICAL STAFF CREDENTIALING APPLICATION FORM For MD; DO; DDS; DMD; DC; DPM; PharmD; PhD; PsyD; OD.
MEDICAL STAFF CREDENTIALING APPLICATION FORM For MD; DO; DDS; DMD; DC; DPM; PharmD; PhD; PsyD; OD. APPLICANT NAME: SPECIALTY: In order to expedite the credentialing process, please complete every item
More informationOhio Department of Insurance
Ohio Department of Insurance STANDARDIZED CREDENTIALING FORM Please complete each section thoroughly. Attach additional sheets where necessary. Type or print clearly in black ink. Sign and date the application.
More informationName of Sex: M F Applicant: Last First Middle. Date of Birth: Social Security Number: Phone: ( ) City State Zip. Phone: ( ) City State Zip
SCHNEIDER REGIONAL MEDICAL CENTER 9048 SUGAR ESTATE ST. THOMAS, U.S.V.I 00802 APPLICATION FOR TEMPORARY PRIVILEGES (USED FOR URGENT PATIENT NEED AND LOCUM TENENS) COMPLETE THE APPLICATION IN FULL. PRINT
More informationVNSNY CHOICE PRACTITIONER CREDENTIALING APPLICATION
Attached please find an application for participation with VNSNY CHOICE. Upon completion, please forward this application to: VNSNY CHOICE Attn: Provider Relations Network Development 1250 Broadway - 11th
More informationALLIED HEALTH PROFESSIONAL CREDENTIALING APPLICATION FORM
ALLIED HEALTH PROFESSIONAL CREDENTIALING APPLICATION FORM Independent Practitioners: Acupuncturist, Audiologist, Dietitian, Licensed Clinical Social Worker, Licensed Marriage and Family Therapist, Licensed
More informationPRACTICE INFORMATION AND LETTER AGREEMENT FORM. COMPLETE, SIGN AND RETURN TO: One Huntington Quadrangle Suite 1N09 Melville, NY 11747
PRACTICE INFORMATION AND LETTER AGREEMENT FORM COMPLETE, SIGN AND RETURN TO: One Huntington Quadrangle Suite 1N09 Melville, NY 11747 PERSONAL DATA Last Name First Name License Number Tax I.D. Number for
More informationCredentialing Application
Credentialing Application 1. NAME Last First MI Degree Gender 2. BIRTH, SOCIAL SECURITY & E-MAIL ADDRESS Date of Birth Social Security # E-Mail Address 3. PRACTICE, OFFICE & SPECIALTY INFORMATION 3.1 Please
More informationSC Uniform Managed Care Provider Credentialing Application
SC Uniform Managed Care Provider Credentialing Application I. PERSONAL INFORMATION Solo Practice Group Practice Name: Last First M.I. Suffix Degree Maiden and/or other name List W-9 name if different Place
More informationEye Medical Provider Practice Application
and subsidiaries Eye Medical Provider Practice Application How to Join the Avesis Network. Complete and sign the application Complete and sign the W-9 Complete and sign the Credential Verification Release
More informationPlease Note: Please send all documentation related to the credentialing portion of this documentation to:
Please ote: The application process is split into different actions. Please send all documentation related to the contracting portion of this documentation to: Fax to: (916)350-8860 Or email to: BSCproviderinfo@blueshieldca.com
More informationCREDENTIALING APPLICATION Please complete all sections. Incomplete applications may delay the credentialing process.
CREDENTIALING APPLICATION Please complete all sections. Incomplete applications may delay the credentialing process. PERSONAL IDENTIFICATION DATA Last Name: First: MI: Degree: Date of Birth: Social Security
More informationGENERAL INFORMATION. English Spanish Arabic Chinese French German Hmong Hindi Laotian Philippine Vietnamese Other
**INCOMPLETE APPLICATIONS WILL DELAY THE CREDENTIALING PROCESS** 1. Please print or type ALL responses. 2. If you need additional space to complete a section, please attach additional sheets. 3. If you
More informationStandardized. Credentialing Form To Be Used By Health Maintenance Organizations Licensed in the State of Missouri
I. GENERAL INFORMATION Standardized Credentialing Form To Be Used By Health Maintenance Organizations Licensed in the State of Missouri COMPLETE EACH SECTION AS THOROUGHLY AS POSSIBLE. PLEASE TYPE OR PRINT
More informationLIBERTY DENTAL PLAN. Provider Credentialing Application. (* Required Fields) *OFFICE PHONE #: ( ) EMERGENCY PHONE #: ( ) *FAX #: ( )
(Complete one application per Provider) (* Required Fields) Credentialing Information: Owner: Associate: *PROVIDER NAME: DDS DMD Other (specify) *DATE OF BIRTH: / / Gender: Male Female Owning Dentist Name:
More informationOREGON PRACTITIONER CREDENTIALING APPLICATION (Not an Employment Application)
OREGON PRACTITIONER CREDENTIALING APPLICATION (Not an Employment Application) Prior to completing this credentialing application, please read and observe the following: Healthcare Organizations may contract
More informationBCBS NC Blue Medicare Credentialing Instructions
BCBS C Blue Medicare Credentialing Instructions Licensed Certified Social Worker (LCSW) Certified Substance Abuse Counselor (CSAC) Licensed Clinical Addiction Specialist (LCAS) Licensed Marriage and Family
More informationLegal Last Name First Middle Professional Title/Degree
IOWA STATEWIDE UNIVERSAL PRACTITIONER RECREDENTIALING APPLICATION Type or print responses in ink. A CV or See CV may not be use in lieu of completing any answers on this application. Review or complete
More informationPROVIDER CREDENTIALING APPLICATION
PROVIDER CREDENTIALING APPLICATION We appreciate your interest in becoming a TRICARE network provider, offering medical services for Prime Beneficiaries. STEP 1. Contact your Provider Education and Relations
More informationNetwork Participant Credentialing Application
Please: Type or print legibly Complete all items. If an item does not apply, enter NA. Do not leave any items blank. Include the following with your application, if applicable: Copy of professional license(s)
More informationTo Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan
To Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan 1. Complete the SC Uniform Managed Care Provider Credentialing Application. 2. Enclose copies of the following items: A. State
More informationThis letter is to let you know that you are due for re-credentialing as a participating provider for AmeriHealth Caritas Louisiana of Louisiana.
ATTN: AmeriHealth Caritas Louisiana Providers RE: Provider Re-Credentialing CAQH ID: Dear Credentialing Contact: This letter is to let you know that you are due for re-credentialing as a participating
More informationPRACTITIONER CREDENTIALING APPLICATION
PRACTITIOER CREDETIALIG APPLICATIO otice to applicants: Encore conducts continuous open enrollment for new practitioners who meet minimum criteria. Minimum criteria for consideration by Encore Credentialing
More informationLIBERTY DENTAL PLAN. Dental Hygienist - Credentialing Application. City: State: DEGREE: City: State: DEGREE:
*Required Fields LIBERTY DENTAL PLAN Dental Hygienist - Credentialing Application Please complete one application per Dental Hygienist Demographic Information: Male Female *HYGIENIST NAME: RDH Other *DATE
More information10111 Richmond Avenue, Suite 400, Houston, Texas (713) / (866) (Toll Free) / (713) (Fax)
Application Date: \ \ Date Available: \ \ Provider s Name: O MD O DO O PA O NP SS # : City: State: Zip: Home Phone ( ) Work Phone ( ) Pager ( ) Cell Phone ( ) E-Mail address: Driver s Lic. # Expires: \
More informationPRACTITIONER RE-CREDENTIALING APPLICATION
PRACTITIOER RE-CREDETIALIG APPLICATIO otice to applicants: Encore conducts continuous enrollment for practitioners who meet minimum criteria. Minimum criteria for consideration by Encore Credentialing
More informationI. PERSONAL INFORMATION. Degree and/or Title SS# . Non-physician Practitioner (Please specify )
Pennsylvania Standard Application This form should be typed or legibly printed in black or blue ink. Please answer all questions completely and fully. If more space is needed than provided on this application,
More informationCRNA INITIAL CREDENTIALING APPLICATION
CRNA INITIAL CREDENTIALING APPLICATION Revised 01/12 GENERAL INSTRUCTIONS LocumTenens.com CVO must credential all providers prior to placement into any practice location. All information requested in this
More informationAPPLICATION FOR REAPPOINTMENT RESEARCH ASSOCIATE
APPLICATION FOR REAPPOINTMENT RESEARCH ASSOCIATE Enclosed is an application for reappointment to the position of Research Associate. We ask that you review the shaded areas to assure that all current information
More informationFacility and Ancillary Credentialing Application INSTRUCTIONS
Facility and Ancillary Credentialing Application INSTRUCTIONS Please complete the application thoroughly in its entirety. The checklist below may not be exhaustive of all materials, but is provided as
More informationALLIED HEALTH STAFF CREDENTIALING APPLICATION
ALLIED HEALTH STAFF CREDENTIALING APPLICATION This application may be used at the hospitals listed below. The Medical Staff office phone numbers of the participating hospitals are as follows: Phone Hospital
More informationIdaho Practitioner Application
Idaho Practitioner Application To use the Idaho Practitioner Application (IPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When a request
More informationWashington Practitioner Application
Washington Practitioner Application To use the Washington Practitioner Application (WPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When
More informationIOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION
IOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION Name: NAME - Last: First: Middle: Title/Degree:! Type or print responses in ink.! Complete this form in its entirety and attach all requested
More informationWashington Practitioner Application
Washington Practitioner Application To use the Washington Practitioner Application (WPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When
More informationIOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION
Name: IOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION NAME: Last Name First Name Middle Name Title Type or print responses in ink. Complete this form in its entirety and attach all requested
More informationHOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION
INSTRUCTIONS: In order to be considered complete: 1. All information must be legible. Please print or type all information 2. Application must be completed in its entirety 3. Must be signed and dated 4.
More informationEFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31
SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 EFFECTIVE DATE: 10/04 Applies to all products administered by the plan except when changed by contract Policy Statement:
More informationCredentialing Application
Credentialing Application If you are active with CAQH it is not necessary for you to complete the application in this packet. In order for Meridian Health Plan to process your contract the following information
More informationMolina Healthcare of Wisconsin, Inc. Practitioner Application
Molina Healthcare of Wisconsin, Inc. Practitioner Application 1. INSTRUCTIONS This form should be: Typed or legibly printed in black or blue ink. Keep a copy of the application on file for future requests.
More informationBehavioral Health Facility and Ancillary Credentialing Application
Behavioral Health Facility and Ancillary Credentialing Application Please complete the application thoroughly in its entirety. The checklist below may not be exhaustive of all materials, but is provided
More informationMassachusetts Integrated Application for Re-Credentialing/Re-Appointment
Massachusetts Integrated Application for Re-Credentialing/Re-Appointment Name (Please type or print) Degrees MA License. Are you currently in the United States on a temporary visa? ** **Identify type of
More informationHOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION
HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION INSTRUCTIONS: In order to be considered complete: 1. All information must be legible. Please print or type all information 2. Application must
More informationIOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION
IOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION NAME: Last Name First Name Middle Name Title Type or print responses in ink. Complete this form in its entirety and attach all requested
More informationSECTION ONE - PERSONAL INFORMATION SECTION TWO - EDUCATION INFORMATION
Attachment H ALLIED HEALTH PROFESSIONALS INITIAL APPOINTMENT ADDENDUM TO THE TEXAS DEPARTMENT OF INSURANCE (TDI) STANDARDIZED CREDENTIALING APPLICATION SECTION ONE - PERSONAL INFORMATION Last Name: First
More informationOrganizational Provider Credentialing Application
Prior to completing this credentialing application, please read and observe the following: INSTRUCTIONS This form should be typed (using a different font than the form) or legibly printed in black or blue
More informationTRINITY HEALTH Minot, North Dakota MEDICAL STAFF PRE-APPLICATION FORM
TRINITY HEALTH Minot, North Dakota MEDICAL STAFF PRE-APPLICATION FORM Application Instructions: Complete the application in full. The application must be typed or neatly printed. Attach additional sheets
More informationMEDICAID ENROLLMENT PACKET
MEDICAID ENROLLMENT PACKET Follow the steps below. This will prevent errors which will delay enrollment. Physicians Only: 1. Answer the one page questionnaire 2. SIGN EACH FORM where it indicates Signature
More informationResearch Associate Application Dear Practitioner:
KALEIDA HEALTH Research Associate Application Dear Practitioner: Enclosed is an application for status as a Research Associate and the appropriate job description. Please return the completed application
More informationIndividual Applicant Information Practices with 5 or more counselors should call (651) for further instruction.
Individual Applicant Information Practices with 5 or more counselors should call (651) 383-8473 for further instruction. Group Practice Name Office Location to Add to Personal Demographics First Name Last
More informationCredentialing Application and Process
Credentialing Application and Process What is Credentialing? Credentialing is the process of obtaining, verifying and assessing the qualifications of a healthcare practitioner to provide patient care services
More informationValues Accountability Integrity Service Excellence Innovation Collaboration
n00256 Recredentialing Process Values Accountability Integrity Service Excellence Innovation Collaboration Abstract Purpose: The purpose of recredentialing is to assure that Network Health Plan/Network
More informationAffiliate Provider Application Instructions and Check Sheet
WellSpan EAP P.O. Box 1827 York, PA 17405 1827 Phone: 866 227 6527 Fax: (717) 851 4493 Affiliate Provider Application Instructions and Check Sheet Enclosed is an Affiliate Provider Application for your
More informationPractitioners may be recredentialed at any time, but in no circumstance longer than a 36 month period.
SUBJECT: PRIMARY CARE AND SPECIALTY PHYSICIAN RECREDENTIALING SECTION: CREDENTIALING POLICY NUMBER: CR-02 EFFECTIVE DATE: 1/01 Applies to all products administered by the Plan except when changed by contract
More informationCREDENTIALING PROCEDURES MANUAL MEMORIAL HOSPITAL OF SOUTH BEND, INC. SOUTH BEND, INDIANA
MEMORIAL HOSPITAL OF SOUTH BEND, INC. SOUTH BEND, INDIANA January 16, 1984 Revised: October 18, 1984 January 19, 1989 April 17, 1989 April 26, 1990 December 20, 1990 January 21, 1993 May 27, 1993 July
More informationDepartment: Legal Department. Approved by:
HAWAII HEALTH SYSTEMS C O R P O R A T I O N Touching Lives Everyday" Policies and Procedures Subject: Credentialing Requirements Department: Legal Department Issued by: Rene McWade, Esq. VP & General Counsel
More informationTHE UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
INSTRUCTIONS FOR NEW APPLICATIONS AND REAPPOINTMENT APPLICATIONS FOR CLINICAL PRIVILEGES AT THE UNIVERSITY OF MISSISSIPPI MEDICAL CENTER Applicant: Department: Please return this form with your application
More information(907) PHONE (907) FAX
3260 Hospital Drive Juneau, AK 99801 Application for Medical, Nurse Practitioner, and Physician Assistant Students Bartlett Regional Hospital Medical Staff Services Office 3260 Hospital Drive Juneau, AK
More informationAPPLICATION FOR APPOINTMENT Northeast Florida Healthcare Organization Revision Date: 9/2016
APPLICATION FOR APPOINTMENT rtheast Florida Healthcare Organization Revision Date: 9/2016 Personal NAME: (LN, FN, MN) AKA or Maiden Name(s) Professional Degree: DMD DOB: SS#: Medicaid #: NPI #: SS# used
More informationAPPLICATION FOR HEALTH PROFESSIONAL LICENSURE
APPLICATION FOR HEALTH PROFESSIONAL LICENSURE Passport Size Photograph Please complete this application on the computer then print and sign. Hand-written applications will not be accepted. Section 1: Application
More informationCOMMUNITY HOWARD REGIONAL HEALTH KOKOMO, INDIANA. Medical Staff Policy POLICY #4. APPOINTMENT, REAPPOINTMENT AND CREDENTIALING POLICY
COMMUNITY HOWARD REGIONAL HEALTH KOKOMO, INDIANA Medical Staff Policy POLICY #4. APPOINTMENT, REAPPOINTMENT AND CREDENTIALING POLICY 1.1 PURPOSE The purpose of this Policy is to set forth the criteria
More informationTIFT REGIONAL MEDICAL CENTER MEDICAL STAFF POLICIES & PROCEDURES
Title: Allied Health Professionals Approved: 2/02 Reviewed/Revised: 11/04; 08/10; 03/11; 5/14 Definition TIFT REGIONAL MEDICAL CENTER MEDICAL STAFF POLICIES & PROCEDURES P & P #: MS-0051 Page 1 of 7 For
More informationCREDENTIALING Section 8. Overview
Overview Credentialing is the process by which the appropriate peer review bodies of the Plan evaluate an individual applicant s background, education, post-graduate training, experience, work history,
More information***CAPS will not begin processing your application until ALL of the above items (numbers 1-4) are returned***
As a service to providers and the community, the Greater Louisville Medical Society (GLMS) offers a Centralized Application Processing Service (CAPS). The GLMS CAPS department verifies: education, training,
More informationCredentialing Application for Hospitals and Facilities
Instructions Credentialing Application for Hospitals and Facilities 1. Please accurately and legibly complete all sections of this Credentialing Application, and mark non-applicable fields with N/A. If
More informationThe Plan will not credential trainees who do not maintain a separate and distinct practice from their training practice.
SUBJECT: PRIMARY CARE AND SPECIALTY PHYSICIAN INITIAL CREDENTIALING SECTION: CREDENTIALING POLICY NUMBER: CR-01 EFFECTIVE DATE: 1/01 Applies to all products administered by the Plan except when changed
More informationApplication Checklist for Facilities
Application Checklist for Facilities Please use the following checklist to complete the credentialing process. Current copies of all items listed below are required for the facility to participate with
More informationCREDENTIALING CHECKLIST
485 Madison Avenue Suite 202 New York, NY 10022 Phone - 212-747-1000 Fax 212-867-3371 CREDENTIALING CHECKLIST Primary Facility Name: Physician Name: (Please duplicate this page for every physician to be
More informationGraduate Medical Education. Division of Cardiology Phone: Fax:
Office of Graduate Medical Education Division of Cardiology Phone: 662-293-7687 Fax: 662-293-4347 Dear Doctor: Attached is an application for our Cardiology fellowship program. Please submit all information
More informationLast Name First Name M.I. Name You Prefer. City State Zip Address. Daytime Phone Evening Phone Best Time to Call. City State If yes, where?
GENERAL INFORMATION Last Name First Name M.I. Name You Prefer Mailing Address How long at this address? City State Zip County If less than a year, previous address How long have you resided in the county?
More informationCREDENTIALING Section 4
Overview Credentialing is the process by which the appropriate peer-review bodies of Ohana Health Plan (the Plan) evaluate the credentials and qualifications of providers, i.e., physicians, allied health
More informationPlease print legibly or type all information. ALL items, including tables, must be completed.
2018 American Board of Pain Medicine MOC Examination Application Form ONLY use this application to apply for maintenance of certification. If you have not yet achieved ABPM Diplomate status, please use
More informationIdaho Practitioner Credentials Verification Checklist
Idaho Practitioner Credentials Verification Checklist The following documentation is required when submitting a practitioner credentialing application. Please complete the information below and return
More informationAgeWell New York Provider Relations 1991 Marcus Avenue Suite M201 Lake Success, NY 11042
Dear Provider/Facility: Thank you for your interest in becoming a network provider/facility for AgeWell New York, LLC. In accordance with our commitment to the quality of health care services delivered
More informationINSTRUCTIONS FOR COMPLETION OF ADVANCED PRACTICE APPLICATION
KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS 66612-1230 (785) 296-4929 INSTRUCTIONS FOR COMPLETION OF ADVANCED PRACTICE APPLICATION Licensure in Kansas
More informationOrganizational Provider Credentialing Application
Organizational Provider Credentialing Application New Mexico Organizational provider identification Legal business name (as reported to the IRS): Medicaid number: Doing Business As (DBA) name (if applicable):
More informationAPPLICATION CHECKLIST IMPORTANT
State of Florida Department of Business and Professional Regulation Division of Professions: Talent Agencies Application for Change of Owner or Operator Form # DBPR TA-2 APPLICATION CHECKLIST IMPORTANT
More informationHONORHealth CREDENTIALING PROCEDURES MANUAL 2017
HONORHealth CREDENTIALING PROCEDURES MANUAL 2017 Table of Contents Part 1 APPOINTMENT PROCEDURES 1.1 Application 1 1.2 Application Content 1 1.3 References 2 1.4 Effect of Application 2 1.5 Application
More informationWEST VIRGINIA BOARD OF PHYSICAL THERAPY 2 Players Club Drive, Suite 102 Charleston, West Virginia Telephone: (304) Fax: (304)
WEST VIRGINIA BOARD OF PHYSICAL THERAPY Charleston, West Virginia 25311 Telephone: (304) 558-0367 Fax: (304) 558-0369 REQUIREMENT CHECKLIST FOR ENDORSEMENT APPLICANTS The following is required for licensed
More informationWhat is your start date? (Date in which you plan to begin seeing patients in the hospital). Specialty SECTION I. IDENTIFICATION DATA
This Application is for Non-employed Clinical Assistants (RN, dental assistant, orthotist, etc) who wish to assist a supervising physician at one or more of our facilities. Advanced Practice Nurses (CRNA,
More informationMEDICAL STAFF CREDENTIALING MANUAL
MEDICAL STAFF CREDENTIALING MANUAL 2016 MOUNT CLEMENS REGIONAL MEDICAL CENTER CREDENTIALING MANUAL TABLE OF CONTENTS I. PROCEDURES FOR APPOINTMENT 4 1. GENERAL PROCEDURE 4 2. APPLICATION FOR INITIAL APPOINTMENT
More informationSAMPLE - Medical Staff Credentialing and Initial Appointment Policy
Subject: Medical Staff Credentialing and Initial Appointment Number: Effective Date: Supersedes SPP# Dated: Approved by: (signature) Distribution: Medical Staff, Credentialing Manual, Medical Staff Office
More informationCredentialing and. Recredentialing. Plan
Credentialing and Recredentialing Plan This Credentialing and Recredentialing Plan may be distributed to applying or participating Licensed Independent Practitioners, Hospitals and Ancillary Providers
More informationIowa Medicaid Universal Provider Enrollment Application. Basic Information
Iowa Department of Human Services Iowa Medicaid Universal Provider Enrollment Application Basic Information To avoid delays in the enrollment process, you should: Complete all required forms listed below.
More informationInstructions and Resource Page for Application for a License to Operate a Child Care Facility
Instructions and Resource Page for Application for a License to Operate a Child Care Facility Instructions: All information on this application must be truthful and correct. Complete this application in
More informationVolunteer Nurse Practitioner Application
Name: Clinic: Volunteer Nurse Practitioner Application AmeriCares Free Clinics, Inc. 88 Hamilton Avenue, Stamford, CT 06902 Phone: (203) 658-9500 ~ Fax: (203) 658-9612 Email: freeclinics@americares.org
More informationState of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training
State of Florida Department of Health Board of Osteopathic Medicine Application for Registration as an Osteopathic Physician in Training Board of Osteopathic Medicine 4052 Bald Cypress Way, #C-06 Tallahassee,
More informationCREDENTIALING PLAN SECTION ONE INDIVIDUAL PROVIDERS
CREDENTIALING PLAN SECTION ONE INDIVIDUAL PROVIDERS I. STATEMENT OF POLICY II. SCOPE A. The purpose of Avera Credentialing Verification Service (CVS) is to provide credentialing and recredentialing primary
More informationCREDENTIALING & PRIVILEGING PRE-APPLICATION DENTISTS, PHYSICIANS AND CERTIFIED REGISTERED NURSE ANESTHETISTS
CREDENTIALING & PRIVILEGING PRE-APPLICATION DENTISTS, PHYSICIANS AND CERTIFIED REGISTERED NURSE ANESTHETISTS August 29, 2017 Dear Applicant, We appreciate your interest in becoming a part of Valleygate
More informationWHITMAN COUNTY CIVIL SERVICE COMMISSION
WHITMAN COUNTY CIVIL SERVICE COMMISSION In compliance with Federal and State equal employment opportunity guidelines, qualified applicants are considered for employment without regards to race, creed,
More informationCredentialing Application Packet. Dear Resident Applicant,
Credentialing Application Packet Salina Family Healthcare Center A Federally Qualified Community Health Center 651 E. Prescott, Salina, KS 67401 Medical Center ~ (785) 825-7251 Dental Center ~ (785) 826-9017
More informationNORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS
NORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS LIMITED VOLUNTEER DENTAL LICENSE INFORMATION PACKET This information packet includes the following: 1) A copy of the Limited Volunteer Dental License Rules
More informationProvider Credentialing
I. Purpose The purpose of this Policy and Procedure is to establish the process including written guidelines and standards for the credentialing and re-credentialing of all clinicians defined in this policy.
More informationMARYLAND BOARD OF PHYSICIANS P.O. Box 2571 Baltimore, Maryland
MARYLAND BOARD OF PHYSICIANS P.O. Box 2571 Baltimore, Maryland 21215 www.mbp.state.md.us E-mail: mdh.mbppadispense@maryland.gov : ADDENDUM FOR PHYSICIAN ASSISTANT (PA) TO DISPENSE PRESCRIPTION DRUGS INSTRUCTIONS
More informationGENERAL APPLICATION FOR EMPLOYMENT
GENERAL APPLICATION FOR EMPLOYMENT Human Resources City of New Smyrna Beach 210 Sams Avenue New Smyrna Beach, Florida 32168 PLEASE PRINT OR TYPE Date of Application Position(s) Applied For The City of
More informationFacility Name: Street Address: City: County: State: Zip: Web Site Address: Office Manager Name: Phone and Ext:
FACILITY CREDENTIALING APPLICATION USI.V1.2010.01 FACILITY INFORMATION Please complete a separate application for each facility. Facility Name: Street Address: City: County: State: Zip: Phone: Fax: Federal
More informationOncology Nurse Practitioner Fellowship Application
Oncology Nurse Practitioner Fellowship Application I. General Information Use this form to apply for full time appointment to the Nurse Practitioner Fellowship in Oncology at Sylvester Comprehensive Cancer
More informationPlease accurately complete the entire application. No action will be taken on applications with missing information.
2508 E. Fox Farm Road, 1-1A Cheyenne, WY 82007 (307) 635-3618 Fax: (307) 635-1442 www.wyhealthworks.org Application for Employment (HealthWorks does not discriminate based on color, creed, religion, national
More informationAPPLICATION FOR NATUROPATHIC DOCTOR
APPLICATION FOR NATUROPATHIC DOCTOR Completion of this application form is necessary for consideration for licensure. Disclosure of this information is voluntary; however, failure to disclose all requested
More informationCredentialing and. Recredentialing. Plan
Credentialing and Recredentialing Plan This Credentialing and Recredentialing Plan may be distributed to applying or participating Licensed Independent Practitioners, Hospitals and Ancillary Providers
More informationState Board of Health
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Adopted by the State Board of Health 03/21/07, effective 10/30/11 State Board of Health 6 CCR 1014-4 COLORADO HEALTH CARE PROFESSIONAL CREDENTIALS APPLICATION
More information