VNSNY CHOICE PRACTITIONER CREDENTIALING APPLICATION

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1 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 Floor New York, NY Tel: (212) Please check the enclosed documents. Failure to return the following documents will result in the return of your application and no processing will take place: Completed Application with signed/dated Release and Authorization form (ENCLOSED) Signed/dated Agreements (2 Originals) (ENCLOSED) Copy of current Professional Liability Insurance Certificate specifying $1,300,000 per occurrence and $3,900,000 in the aggregate Copy of Current License Registration Copy of Current DEA Certificate (IF APPLICABLE) Copy of ECFMG certificate (IF APPLICABLE) Copy of Curriculum Vitae/Resume Copy of Appointment/Reappointment Letters from all Hospitals and Facilities at which you have privileges Copy of Certificate from Residency/Fellowship Program (if not Board Certified) Copy of Board Certificate of Specialty or letter stating eligibility status (IF APPLICABLE) Completed and Signed W-9 Form(s) (if multiple pay to Tax IDs, separate W-9 for each)

2 Type or print responses in ink. Complete this form in its entirety and attach all requested documentation and explanations. A CV or See CV may not be used in lieu of completing any answers on this application except in Section H. If a question does not apply to you, answer with Non-Applicable or N/A. If additional space is necessary to provide answers, attach additional sheet(s) of paper. All dates must be formatted as: Month/Day/Year; Type/print present in Ending Date year for current status of activity, if applicable. SECTION A: DEMOGRAPHIC INFORMATION Provider Name: Last Name First Name Middle Name Social Security Number: Birth Date: / / Gender (For Directory Purposes): Male Female Address: Special languages spoken/translated by you: Applying as: PCP Specialist PCP & Specialist Primary Specialty Board Certified: Yes No Sub Specialty 1: Board Certified: Yes No Sub Specialty 2: Board Certified: Yes No Type Individual Number Group Number National Provider Identifier (NPI): Medicare Number: Medicaid Number: Federal DEA: 2

3 SECTION B: OFFICE/PRACTICE SITE INFORMATION (please photocopy this page and complete for additional offices/practice sites.) OFFICE/PRACTICE SITE #1 OFFICE/PRACTICE SITE #2 Practice Type: Solo Practice Group Practice Solo Practice Group Practice Practice Location Name: Street Address Line 1: Street Address Line 2: City, State: Zip Code: Office Telephone No. Office Fax No.: Accepting new patients: Yes No Existing Patients Only Yes No Existing Patients Only Wheelchair accessible: Yes No Yes No Office accessible via public transportation: Yes No Yes No Services available for hearing impaired: Yes No Yes No Estimated waiting time in days for appointments: Practice-specific limitations on patients (age, gender, scope of practice, etc.): CLIA Certificate No.: Is Office-Based Surgery (OBS) (as defined in NYS 2007 Public Health Law Chapter 365 Section 230- d) performed at this site? If OBS is performed here, accreditation by: Non-urgent/Elective days Urgent days Non-urgent/Elective days Urgent days Yes No Yes No Accreditation Association for Ambulatory Health Care Accreditation Association for Ambulatory Health Care ***Please attach a copy of the accreditation certificate or letter.*** American Association for Accreditation of Ambulatory Surgery Facilities, Inc. The Joint Commission If not accredited, please explain below: American Association for Accreditation of Ambulatory Surgery Facilities, Inc. The Joint Commission If not accredited, please explain below: Accreditation Expires: / / / / 3

4 Sunday Monday Tuesday Wednesday Thursday Friday Saturday List Your Office Hours (hours available to see patients): OFFICE/PRACTICE SITE #1 OFFICE/PRACTICE SITE #2 Open Close Open Close Do you make home visits? Yes No Describe your coverage arrangements (24x7): List the name(s) of all provider back-ups: Name: Specialty: Name: Specialty: Name: Specialty: Name: Specialty: Full Name: Office Manager OFFICE/PRACTICE SITE #1 OFFICE/PRACTICE SITE #2 Telephone No.: Fax No.: 4

5 Full Name: Billing Information OFFICE/PRACTICE SITE #1 OFFICE/PRACTICE SITE #2 Tax Identification No.: Checks Payable To: Street Address Line 1: Street Address Line 2: City, State: Zip Code: Telephone No.: Fax No.: SECTION C: LICENSURE INFORMATION ECFMG Information: Certification Number: Certification Date: / / Provide all license information, both current and expired (copy and include additional sheets if necessary): Name as it appears on NYS License: NYS License Type: (Medical, Dental, etc.) NYS License Number: Effective Date: / / Expiration Date: / / OTHER LICENSE: Name as it appears on the License: License Type: (Medical, Dental, etc.) License Number: Effective Date: / / Expiration Date: / / Issued in what State: Country: 5

6 SECTION D: MALPRACTICE HISTORY AND LIABILITY COVERAGE Current Carrier: Address: City: State: Zip Code: Amount of Coverage: $ per occurrence; $ aggregate Policy Number: Dates of Coverage: From: / / To: / / If you have any professional malpractice activity within the past ten (10) years to report on this application, complete this page for each professional liability incident (copy and include additional sheets if necessary). Description of allegation or action taken: Date of incident: / / Date of claim or suit filed: / / Location of incident: Insurance carrier name: Insurance carrier address: City: State: Zip Code: Phone Number: ( ) Fax Number: ( ) Describe your involvement with the patient s care. Your narrative must include the following at a minimum: 1) Condition and diagnosis at time of incident 2) Dates and description of treatment rendered 3) Condition of patient subsequent to treatment Your Status: Primary Defendant Co-Defendant Other (specify) Claim Status: Open Pending Closed If closed, indicate the date closed and case outcome: Date Closed: / / Dismissed with prejudice Settled with Prejudice Judgment for Defendant Dismissed without prejudice Settled without Prejudice Judgment for Plaintiff Amount of settlement or judgment paid on your behalf (if any): $ Date of payment: / / 6

7 SECTION E: HOSPITAL AND FACILITY PRIVILEGES List all hospitals and facilities at which you have pending or currently hold privileges and describe the type(s) of privileges, (do not include privileges during internship, residency or training) (copy and include additional sheets if necessary): Hospital/Facility Name: Street Address: City: State: Zip Code: Phone Number: ( ) Fax Number: ( ) Active Provisional Temporary Pending Other: Date From: / / To: / / Hospital/Facility Name: Street Address: City: State: Zip Code: Phone Number: ( ) Fax Number: ( ) Active Provisional Temporary Pending Other: Date From: / / To: / / SECTION F: EDUCATION & TRAINING Copy and include additional sheets if necessary: MEDICAL SCHOOL: Institution Name: City: State: Country: Dates Attended: Beginning Date: / / Ending Date: / / Degree Received: Specialty: NON-PHYSICIANS MUST COMPLETE THIS SECTION: Level: UNDERGRADUATE MASTERS PHD OTHER POST-GRADUATE TRAINING Institution Name: City: State: Country: Dates Attended: Beginning Date: / / Ending Date: / / Degree Received: Specialty: Level: UNDERGRADUATE MASTERS PHD OTHER POST-GRADUATE TRAINING Institution Name: City: State: Country: Dates Attended: Beginning Date: / / Ending Date: / / Degree Received: Specialty: 7

8 Explain any gaps in education: Level (check one): INTERNSHIP RESIDENCY FELLOWSHIP OTHER Institution Name: City: State: Country: Dates Attended: Beginning Date: / / Ending Date: / / Type/Specialty: Year Completed: If not completed, please explain below. Level (check one): INTERNSHIP RESIDENCY FELLOWSHIP OTHER Institution Name: City: State: Country: Dates Attended: Beginning Date: / / Ending Date: / / Type/Specialty: Year Completed: If not completed, please explain below. Level (check one): INTERNSHIP RESIDENCY FELLOWSHIP OTHER Institution Name: City: State: Country: Dates Attended: Beginning Date: / / Ending Date: / / Type/Specialty: Year Completed: If not completed, please explain below. Explain any incomplete training, any gaps in training, or any gaps between education and training: SECTION G: BOARD CERTIFICATION Please give the following information for each certification you have completed, or are eligible to complete (see below) (copy and include additional sheets if necessary): Not Applicable Board Certified: Board Name/Certificate Type/Issued By: Board Specialty: Board Sub-specialty: Certificate Number: Original Certification Date: / / Expiration Date: / / Recertification Date(s): / /, / / 8

9 Board Certified: Board Name/Certificate Type/Issued By: Board Specialty: Board Sub-specialty: Certificate Number: Original Certification Date: / / Expiration Date: / / Recertification Date(s): / /, / / Board Certified: Board Name/Certificate Type/Issued By: Board Specialty: Board Sub-specialty: Certificate Number: Original Certification Date: / / Expiration Date: / / Recertification Date(s): / /, / / ELIGIBLE FOR CERTIFICATION (Attach letter confirming admissibility): Board Name/Certificate Type: Written Examination: Completed / / Scheduled / / Oral Examination: Completed / / Scheduled / / Admissibility Dates: From / / to / / SECTION H: PROFESSIONAL HISTORY Curriculum Vitae (CV) attached. If so, you do not have to complete the section below. List all professional career experience and mark appropriate box for type (include additional sheet(s) if necessary), beginning with current professional activity. Be sure to explain any chronological gaps below (if applicable). Type: PRACTICE/EMPLOYMENT ACADEMIC/FACULTY MILITARY PUBLIC HEALTH OTHER Location Name: Position: Street Address: City: State: Zip Code: Beginning Date: / / Ending Date: / / Type: PRACTICE/EMPLOYMENT ACADEMIC/FACULTY MILITARY PUBLIC HEALTH OTHER Location Name: Position: Street Address: City: State: Zip Code: Beginning Date: / / Ending Date: / / 9

10 SECTION H: PROFESSIONAL HISTORY - continued Explain any gaps in professional history as indicated above or in attached curriculum vitae: 10

11 SECTION I: QUALITY FOCUSED QUESTIONS Please be sure to carefully read and answer each question below, and explain any yes answers on page Have you ever voluntarily or involuntarily surrendered or relinquished a state, district or federal professional license or registration (DEA or State Controlled Substance Certificate), board certification or any other certification? YES NO 2. Have clinical privileges ever been denied, revoked, suspended or restricted in any way? YES NO 3. Has your state license ever been subjected to any revocation, suspension, probation, or other disciplinary action by any state licensing authority? YES NO 4. Have there been any previously successful or are there any currently pending challenges, complaint(s),sanction(s), disciplinary actions(s), investigations or denials recommended YES NO 5. Have you ever been convicted of any crime related to your clinical, medical, dental or professional practice?. YES NO 6. Regarding Medicare, Medicaid, or any other governmental health-related programs, have you ever been convicted of a crime or been subjected to civil penalties, disciplinary proceedings, investigations, denial of or suspension from participation, or had any type of sanction? YES NO 7. Do you have any felony, grand jury indictment, or other criminal charges pending?.. YES NO 8. Have you ever been convicted of, found guilty of or pled no contest to a felony, grand jury indictment or crime, other than a minor traffic violation?.. YES NO 9. Do you presently have a physical, mental or emotional condition (including alcohol or drug dependence) that affects or is reasonably likely to affect your ability to perform your professional duties appropriately or which could adversely affect the quality of care rendered by you to patients or jeopardize the safety of patients?.. YES NO 10. Have you ever had a malpractice case filed against you? (If yes, explain). YES NO 11. Have you ever had a malpractice judgment entered against you? (If yes, explain) YES NO 12. Have any malpractice settlements ever been made on your behalf? (If yes, explain) YES NO 13. Has/have any adverse action(s) or malpractice report(s) about you been made to the National Practitioner Data Bank, or any other databank?. YES NO For any YES answers to the Questions above, please provide detailed explanation on the next page. 11

12 SECTION I: QUALITY FOCUSED QUESTIONS - continued Question # Detailed Explanation If there is additional information about you or your practice that you feel will have a bearing on the consideration of this application, please provide details (attach an additional page if needed): 12

13 Release and Authorization I authorize VNSNY CHOICE and Healthplex Credentialing Verification Organization (CVO), subsidiaries, successors, employees, and agents to consult professional liability carriers, managed care organizations, State Boards of Education and other persons or entities in order to obtain information concerning my qualifications including without limitation my professional competence and conduct. I consent to release to VNSNY CHOICE and Healthplex Credentialing Verification Organization (CVO), any and all information that might be relevant to the evaluation of my qualifications, including all information that might otherwise be considered confidential or privileged. I authorize VNSNY CHOICE and Healthplex Credentialing Verification Organization (CVO) to release this information, as well as any quality assurance data relating to me, to any entity related to VNSNY CHOICE and Healthplex Credentialing Verification Organization (CVO), or its affiliates. I release VNSNY CHOICE and any and all persons or entities providing information about me to VNSNY CHOICE from any and all liability connected with or arising from the release of such information, provided that such party(ies) was acting in good faith and without malice. I further release VNSNY CHOICE and Healthplex Credentialing Verification Organization (CVO) from any and all liability for their acts performed in good faith and without malice in evaluating my application, and any decisions related to my application or credentialing status. I understand that I have the burden of providing adequate information to VNSNY CHOICE and Healthplex Credentialing Verification Organization (CVO) to demonstrate my qualifications. I understand and agree that any misstatement or material omission in this application will constitute grounds for rejection of my application or summary dismissal as a participating provider in any and all entities credentialed by VNSNY CHOICE and Healthplex Credentialing Verification Organization (CVO). If any material change occurs in the information I have provided in this application, which in any way is relevant to my performing the essential functions of my practice, or affects my professional status in any way, I understand and agree that it is my obligation to notify VNSNY CHOICE and Healthplex Credentialing Verification Organization (CVO) within ten days of said occurrence. Failure to comply with this obligation may constitute grounds for my summary dismissal as a participating provider in any and all networks credentialed by VNSNY CHOICE and Healthplex Credentialing Verification Organization (CVO). I understand that all statements on this application whether prepared by an employee or me are to be considered statements made by me. I attest that the information contained in this application is correct and complete. / / Practitioner s printed name Practitioner s Signature (in pen please) Date 13

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