Credentialing Application

Transcription

1 Credentialing Application 1. NAME Last First MI Degree Gender 2. BIRTH, SOCIAL SECURITY & ADDRESS Date of Birth Social Security # Address 3. PRACTICE, OFFICE & SPECIALTY INFORMATION 3.1 Please check the type of participation for which you are applying. Primary Care Physician Specialist Both 3.2 Specialty(ies) (List each specialty as you would like listed in the directory) Specialty Board Certified Expiration 3.3 Specialty Focus or Area of Expertise 3.4 Procedures Performed in the Office (TE: Effective July 1, 2009 accreditation required for New York providers. If applicable, please attach accreditation certificate and other relevant details) 4. STATE LICENSES 4.1 Professional Licensure State License # Status Expiration Date State License # Status Expiration Date 4.2 Certificate/ID numbers Medicaid # CAQH # DEA # Medicare # Worker s Comp # CDS # NPI # Contract Version: V Revised:

2 5. DIRECTORY INFORMATION 5.1 Address Primary Office Secondary Office Tertiary Office Address City, State, Zip Telephone # w/ Ext. Fax # Federal Tax ID (Copy of W-9 required) Address Type SERVICE BILLING SERVICE BILLING SERVICE BILLING BOTH BOTH BOTH 5.2 Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday Primary Office Secondary Office Tertiary Office Contract Version: V Revised:

3 5.3 Current Hospital Affiliation(s) (Please list hospital names with which you have active association, employment, privileges or practice. Specify type of privileges, e.g., attending, consulting, etc. If additional space is required, please attach a separate sheet.) Facility Name Address City, State, Zip Dept. (Primary) Date of Association Type of Privileges (Secondary) 6. SUPERVISING OR COLLABORATING PHYSICIANS(S) (Must be participating with MagnaCare) 1. Name Address City, State, Zip Telephone/ Ext EDUCATION/TRAINING 7.1 Medical/Dental School/Professional School School Name Address, City, State, Zip Degree Awarded Dates of Attendance (Month/Year) From To 7.2 ECFMG/FIFTH PATHWAY Certificate Number Date Awarded/Completed Contract Version: V Revised:

4 7.3 RESIDENCIES/FELLOWSHIPS Institution Address, City, State, Zip Specialty Level Completed Dates of Attendance (Month/Year) From To 8. PROVIDER INFORMATION Please provide a full written explanation for any responses to the following Has your license to practice medicine or prescribe any narcotic in any state been denied, revoked, 8.1 or otherwise limited? Has a hospital, government or state agency, licensing board, or medical association taken any 8.2 disciplinary or adverse action against you? Have you been placed on probation, fined, suspended, reprimanded, or censured by any Federal, 8.3 State, or Local agency, including but not limited to Medicare, Medicaid, or CLIA program authorities? Have you been convicted for violation of a law other than a traffic offense or been the subject of a 8.4 criminal indictment? Do you have any physical or mental health condition, treated or untreated, which in any way 8.5 impairs your ability to practice to the fullest extent or to perform the essential functions of your license and requested specialty(ies) with or without accommodations? Do you have or have you had any chemical dependency/substance abuse problems, treated or untreated, including but not limited to alcohol, illegal or regulated substances, which in any way 8.6 impairs your ability to practice to the fullest extent of your license and requested specialty(ies) or which in any way may pose a risk of harm to your patients? Have any malpractice suits been filed against you within the last 5 years? If yes, please attach all 8.7 relevant details. 9. PROFESSIONAL LIABILITY 9.1 Current Liability Insurance Carrier Name Policy # Exp. Date Limits Status For any responses, please attach explanation sheet. Have you ever been denied professional liability insurance, or has your coverage been cancelled, or has a surcharge been imposed because of your claims experience? Contract Version: V Revised:

5 Provider Credentialing Signature Page MagnaCare Administrative Services, LLC ( MagnaCare ) -- Please Read Carefully Before Signing -- I hereby authorize MagnaCare and/or its designees to consult with hospitals, institutions, or healthcare organizations with which I have been associated and with others who may have information bearing on my professional competence, character, ethical qualifications, pending malpractice suits, judgments or settlements of a malpractice action or any findings of professional misconduct. I hereby further consent to the inspection by MagnaCare and/or its designees of all documents that in their opinion may be material to an evaluation of my professional qualifications and competence, for utilization and quality assurance purposes, and to evaluate my moral and ethical qualifications for membership. I hereby consent to the sharing of my credentialing information by MagnaCare with third party entities involved in MagnaCare- sponsored marketing or affinity programs and I release MagnaCare and any such third party entities from any liability arising from, or relating to, their use of my information. I hereby release from liability all representatives of MagnaCare and/or its designees for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I hereby release from any liability any and all individuals and organizations who provide information to MagnaCare and/or its designees in good faith and without malice concerning my professional competence, ethics, character and other qualifications. I hereby consent to the release and exchange of information relating to any disciplinary action, suspension, or curtailment of surgical-medical privileges and any other information which may be necessary to obtain in order to fulfill statutory and regulatory requirements to MagnaCare and/or its designees or to hospitals where I may have or apply for staff privileges. I hereby further authorize MagnaCare and/or its designees to communicate to hospitals, institutions and healthcare organizations with a legitimate interest therein, any information concerning my professional competence, character, ethics and conduct, as well as any other information which must be disclosed in accordance with statutes and regulatory requirements that MagnaCare and/or its designees may have or acquire, and, where such communication is made in good faith and without malice, I consent thereto and agree to hold MagnaCare and its authorized representatives and/or its designees free of liability therefore. I hereby authorize my Medical Liability Insurance carrier to annually provide MagnaCare and/or its designees with a copy of my Certificate of Insurance of Professional Liability Coverage (insurance holder) and updated claims experiences. In the event of any material change in, cancellation of, or failure to renew any professional liability coverage, I request and authorize MagnaCare and/or its designees be given immediate written notice by any professional liability carrier. I hereby release my Medical Liability Company and its representative for the provision of such information to MagnaCare and/or its designees. A photocopy of this authorization shall be as effective as the original when so presented. I have received for my records and have read MagnaCare s Provider Agreement. If accepted as a Participating Provider in the MagnaCare Network, the agreement and amendments shall become effective on the date indicated on the MagnaCare acceptance notification (The Effective Date ). I hereby certify that all of the information provided pursuant to the above questions and requests included in this application are complete, true and correct to the best of my knowledge and belief and fully understand that any significant mis-statements in or omissions from this application constitutes cause for dismissal of appointment or cause for summary dismissal from the network. If any material changes occur in the information provided in this application affecting my professional status, I understand and agree that it is my obligation to notify MagnaCare Administrative Services, LLC within five (5) business days of such occurrence. Print Name: Primary Specialty: NPI #: Phone #: CAQH #: License #: Signature: ( No Signature Stamps) MagnaCare Received and Accepted: Date: Date: Contract Version: V