CO, DC, IL, MD, MO, NC, NM, OH, OK, OR,

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1 Thank you for using our online Physician Re-Credentialing Application! Please print out the application attached and complete each section completely. Be sure to include the supporting documents requested on the check sheet. Failure to provide these documents could possibly cause a delay in your application s processing time. Once completed, mail the application and supporting documents to: MedSolutions, Inc. Attn: Credentialing Dept. 730 Cool Springs Blvd, Ste. 800 Franklin, TN Important Note: If your reading radiologist(s) provide services in one of the following states, you must submit your application using your state mandatory credentialing form. Please do not use the MedSolutions credentialing application for the following states: CO, DC, IL, MD, MO, NC, NM, OH, OK, OR, and TX. For those states mentioned above, please submit: 1.) Your state mandated credentialing application, 2.) The requested supporting documents from the check sheet, 3.) The Modalities Section from page 3 of the MedSolutions credentialing application. If you have any questions, please contact the Credentialing Dept. at (800) or by at credentialing@medsolutions.com. Sincerely, The MedSolutions Credentialing Dept.

2 Tips to Help Eliminate the Need for Returns or Delays in Processing Your Physician Re-Credentialing Application Tips to help eliminate the need for returns or delays in processing your application: Note: MedSolutions currently only credentials facilities that offer high tech (CT, MR, PET and NM) modalities The following documents MUST be included or your application CANNOT be processed. Copy of Current State Licensure Copy of Current DEA and/ or CDS, as applicable Copy of Current Professional Liability Insurance Face Sheet (Include a listing of covered physicians) Copy of Current Facility s General Liability Insurance Face Sheet. Copy of Current Curriculum Vitae (CV) Physicians signature required (no stamped signatures) AND Dated Attestation (within 90 days) Please Remember: Answer ALL Yes and No questions. If a section is not applicable, write N/A. Include your SSN, Date of Birth, NPI, and Medicare number. Important Notes: During the re-credentialing process performed by the MedSolutions Credentialing Department the Practitioner has the right to be informed of the status of their application. MedSolutions Credentialing Department will honor written requests, fax submissions, and telephone calls. It is MedSolutions policy to answer all inquiries within 24 hours or the next business day. On pages 2 & 3, Education and Internships, Residencies, Fellowships Sections-The physician members of the Credentials Committee will appreciate you filling in the requested information rather than writing See CV. On page 3, Employment History Section- A complete chronology of your work history is required. There should be no unexplained gaps of more than (6) six months in sequence and you must list a minimum of (5) five years of work history. This will eliminate the need to request additional information. On page 3, Attestation Section- This is one of the most carefully scrutinized areas of the application. Please read each statement on the application carefully before answering. If you answer yes to any question that requires an explanation, please remember to include that attachment. MSI cannot accept this application unless the physician has signed and dated the attestation. A stamped signature or date is not acceptable. Address: MedSolutions, Inc. attn: Credentialing Department 730 Cool Springs Blvd. #800, Franklin, TN Phone: (800) credentialing@medsolutions.com Tip Sheet 02/05 Revised: 01/07, 1/08 Page 1 of 1

3 Network Participation Re-Credentialing: Physician Complete one application per Reading Radiologist. Make copies as needed. DEMOGRAPHICS: If you answer yes to any of the following questions please provide an attachment with explanation. PROVIDER NAME/DEGREE: SOCIAL SECURITY # DOB : GENDER M F PHYSICIAN TIN : MEDICARE # NPI # SPECIALTY : Have you incurred any revocations, suspensions or sanctions as a Medicare or Medicaid provider? Yes No READING RADIOLOGIST GROUP NAME : PHONE # FACILILTY NAME: ADDRESS CITY STATE ZIP PHONE # FAX # CREDENTIALING CONTACT INFORMATION: CONTACT NAME ADDRESS PHONE # FAX # PRIVILAGES: Please list the hospital(s) at which you currently have privileges (consulting, active or provisional) for each modality requested: HOSPITAL 1 HOSPITAL 2 If you answer yes to any of the following questions, please provide an attachment with explanation. Yes No Have your hospital privileges been revoked, suspended or limited since last credentialed? CITY/ST CITY/ST Has there been any voluntary termination of professional or medical staff membership or voluntary limitation, reduction or loss of clinical privileges at a hospital or other health care delivery setting since last credentialed? LICENSURE: If you answer yes to any of the following questions, please provide an attachment with explanation. STATE 1 LICENSE # EFFECTIVE DATE EXPIRATION DATE STATE 2 LICENSE # EFFECTIVE DATE EXPIRATION DATE Are you licensed in any other states? Yes No If so, please list: If you answer yes to any of the following questions, please provide an attachment with explanation. Yes No Have you had a provider license investigated, censured or revoked since last credentialed? If yes, provide description, including state. Are there any state licensing investigations or actions since last credentialed? Have there been any restrictions placed on your DEA license since last credentialed? Has your DEA license ever been suspended or revoked since last credentialed? Are there any DEA state licensing investigations or actions since last credentialed? DEA LICENSE # DEA EFFECTIVE DATE DEA EXPIRATION DATE

4 LICENSURE QUESTIONS: IF YOU ANSWER YES TO ANY OF THE FOLLOWING QUESTIONS PLEASE PROVIDE AN ATTACHMENT WITH EXPLANATION AND CONCISE FACTS, DETIALS, CARRIER CLAIMS SUMMARY AND CURRENT STATUS OR DISPOSITION. Yes No Have you been denied membership, or been subject to disciplinary proceedings by any medical or professional organization since last credentialed? Has any disciplinary action been taken against you or your license by any state licensing board and/or is any such action pending and/or is any investigation of you by any such board underway since last credentialed? Have you been convicted of a felony or any other criminal charge since last credentialed? Do you have any inability, for any reason, to perform any of the mental and physical functions normally associated with practice in the provider s specialty, with or without accommodation? Do you engage in the unlawful use of drugs, including the use of prescription drugs without supervision of a licensed health care professional, or participate in treatment for the addiction of alcohol? For purposes of this question, currently means recently enough so that the use of drugs may have an ongoing impact on one s ability to practice medicine. MALPRACTICE INSURANCE COVERAGE: (READING RADIOLOGIST) MALPRACTICE INSURANCE CARRIER MALPRACTICE INSURANCE POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE MALPRACTICE COVERAGE PER OCCURRENCE MALPRACTICE COVERAGE IN AGGREGATE GENERAL LIABILITY INSURANCE COVERAGE: (FACILITY) GENERAL LIABILITY INSURANCE CARRIER GENERAL LIABILITY POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE GENERAL LIABILITY PER OCCURRENCE GENERAL LIABILITY COVERAGE IN AGGREGATE If you answer yes to any of the following questions, please provide an attachment with explanation. Include clinical details and settlement amounts for all open, closed, settled or litigated cases. Yes No Have any malpractice allegations been filed against you, been settled or lost in the past 5 years? Has your professional liability coverage ever been restricted, suspended, refused, revoked or denied? EDUCATION : INTERNSHIP FOCUS CITY STATE/COUNTRY START DATE END DATE RESIDENCY FOCUS CITY STATE/COUNTRY START DATE END DATE FELLOWSHIP FOCUS CITY STATE/COUNTRY START DATE END DATE BOARD CERTIFICATIONS: BOARD CERTIFIED? Yes No BOARD ELIGIBLE? Yes No SPECIALTY AREA? BOARD SPECIALTY 1 ORIGINAL EFFECTIVE DATE EXPIRATION DATE BOARD SPECIALTY 2 ORIGINAL EFFECTIVE DATE EXPIRATION DATE If NOT board certified, indicate any of the following that apply. I HAVE TAKEN EXAM, RESULTS PENDING FOR: I HAVE TAKEN PART I AND AM ELIGIBLE FOR PART II OF THE: I AM INTENDING TO SIT FOR THE BOARDS ON: I AM NOT PLANNING TO TAKE THE BOARDS.

5 EMPLOYMENT HISTORY: Please list employers for the past THREE years-starting with current position. EMPLOYER/LOCATION DATES OF EMPLOYMENT-MONTH/YEAR Are there any work or education gaps of six months or greater? If yes, please provide an explanation. Yes No This section must be completed or your application can not be processed. MODALITIES SECTION: Please indicate which of the following high tech modalities the facility currently provides? CT MR PET Cardiac NM Is the facility currently accredited by the ACR or IAC in any of the following modalities? CT MR PET Cardiac NM Please indicate which of the following modalities you currently provide at the facility where you seek credentialing? CT MR PET Cardiac NM Note: Complete the volume section below for each modality selected. CT Volume: Interpret at least 300 CT exams in the past 36 months. MR Volume: Interpret at least 300 MR exams in the past 36 months? PET Volume: Interpret at least (see below) exams in the last 36 months? NM Volume: Interpret at least 15 scans per month in the past 24 months? 30 Brain Yes No Yes No Yes No 80 Oncologic Yes No 20 Cardiac Yes No Yes No CT specific CME: 15 hours in the past 36 months. (half of which ) MR specific CME: 15 hours in the past 36 months. (half of which ) PET specific CME: 20 hours in the past 36 months. (half of which ) NM specific CME: 15 hours in the past 36 months. (half of which ) Note: Please include year and category for all CME attachments. Note: Please include year and category for all CME attachments. Note: Please include year and category for all CME attachments. Note: Please include year and category for all CME attachments. Note 1 : Applicants that are not currently working at an ACR accredited facility in MRI/CT/NM or an IAC accredited facility in NM or MRI will be required, each time credentialed, to provide volume and CME hour requirements as listed in the charts above. Note 2 : Applicants requesting PET modality that completed a Residency or Fellowship prior to the year 2000 will be required, each time credentialed, to provide volume and CME hour requirements listed in the charts above. ATTESTATION: I certify that the information provided is accurate and complete. I understand that submission of this information does not entitle me to participation in the MedSolutions network. I authorize the release of all information necessary to validate my application and to certify or verify the validity of my license, malpractice activity, legal actions, and any other information that shall be required to validate credentials and qualifications. I release MedSolutions and its employees or agents from any and all liability from acts performed in good faith in obtaining and verifying such information. I agree to notify MedSolutions within five business days of any material change to the information submitted on this application. I understand that the information disclosed is not publicly available and will be treated as confidential. Physician s Signature Print Name Signature of Person Filling Out This Application Date Direct Phone Number & Applicable Extension Address: MedSolutions, Inc. attn: Credentialing Department 730 Cool Springs Blvd. #800, Franklin, TN Phone: (800) credentialing@medsolutions.com

6 Last updated: March 5, 2008 MedSolutions Network Physician Credentialing Standards A. Radiologists: 1. Completion of all relevant facility and physician credentialing forms. 2. Must possess a Doctor of Medicine (MD) degree or Doctor of Osteopathy (DO) degree. 3. Each radiologist is primary-source verified as described in the credentialing section. 4. Current facility accreditation (where the applicant practices greater than 50% of his/her professional time) by the American College of Radiology (ACR) in MRI/CT/NM or the Intersocietal Accreditation Commission (IAC) in NM or MRI will be accepted as meeting credentialing requirements in those areas for interpreting physicians. Note: ACR or IAC accreditation in PET and IAC accreditation in CT does not currently fulfill this requirement, but may be considered on a case-by-case basis. 5. Each physician at the facility who is a Radiologist, providing Facility Services to Members, must be board certified by the American Board of Radiology (ABR) in Radiology or Diagnostic Radiology, by the American Osteopathic Board of Radiology (AOBR), or by the Royal College of Physicians and Surgeons of Canada (RCPSC). 6. Radiologists who provide professional interpretation of Nuclear Medicine studies, including PET, must be board certified in Radiology or Diagnostic Radiology, Nuclear Radiology, or Nuclear Medicine by the ABR, American Board of Nuclear Medicine (ABNM), AOBR, American Osteopathic Board of Nuclear Medicine (AOBNM), or RCPSC. 7. If not Board certified, Radiologist must be within one year following completion of a Diagnostic Radiology Residency or Fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME), with plans for completing the board examination within one year of the date of application. 8. Each physician must posses a current license that is in good standing, to practice medicine in the state where services are to be rendered. 9. Must provide proof of current professional liability insurance coverage. 10. Must provide proof of current facility general liability insurance coverage. 11. Foreign medical school graduates must submit an Educational Commission for Foreign Medical Graduates (ECFMG) Certificate. 12. Provide disclosure of malpractice history for the preceding 5 years. 13. Provide disclosure of any disciplinary issues or reportable actions to the NPDB or state medical board, or any sanction against the applicant s ability to possess a current Drug Enforcement Administration (DEA) Certificate or State level Controlled Dangerous Substance (CDS) Certificate. 14. Applicants that are not currently working at an ACR accredited facility in MRI/CT/NM or an IAC accredited facility in NM or MRI will be required, each time credentialed, to provide CME hours and volume requirements as listed in the charts below. Exception: Documentation showing successful completion of a Radiology Residency or Fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME) within the last 24 months is exempt from this requirement. 15. Applicants requesting PET modality that completed a Residency or Fellowship prior to the year 2000 will be required, each time credentialed, to provide CME hours and volume requirements listed in the charts below. CT specific CME: 15 hours in the past 36 MR specific CME: 15 hours in the past 36 PET specific CME: 20 hours in the past 36 NM specific CME : 15 hours in the past 36 CT Volume: Board certified radiologist must interpret at least 300 CT exams in the past 36 months. MR Volume: Board certified radiologist must interpret at least 300 MR exams in the past 36 months. PET Volume: Board certified radiologist must interpret 30 Brain Exams, 80 Oncologic Exams, 20 Cardiac Exams in the past 36 months. NM Volume: Board certified radiologist must interpret at least 15 scans per month in the past 24 months.

7 B. Non- Radiologist Licensed Practitioners: 1. Completion of all relevant facility and physician credentialing forms. 2. Each licensed practitioner is primary-source verified as described in the credentialing section. 3. Must be a licensed practitioner. 4. Each licensed practitioner at facility must be board certified by the ABMS or AOA in the specialty practiced. 5. Current facility accreditation (where the applicant practices greater then 50% of his/her professional time) by the American College of Radiology (ACR) in MRI/CT/NM or the Intersocietal Accreditation Commission (IAC) in NM or MRI will be accepted as meeting credentialing requirements in those areas for interpreting practitioners. We are not currently accepting ACR or IAC accreditation in PET nor are we accepting IAC accreditation in CT as meeting credentialing requirements. 6. Licensed practitioners who provide professional interpretation of CT examinations: Must show proof of completion of an accredited specialty residency and 50 hours of Category 1 CME hours in the performance as well as interpretation of CT in the subspecialty where CT reading occurs, and interpretation and reporting of 300 cases during the past 36 months in a supervised situation. 7. Licensed practitioners who provide professional interpretation of MR examinations: Must show proof of completion of an accredited specialty residency and 50 hours of Category 1 CME hours in MR to include, but not limited to: MRI physics, recognition of MRI artifacts, safety, instrumentation, and clinical applications of MRI in the subspecialty area where MRI readings occur and 300 MRI cases in that specialty area shall have been interpreted and reported in the past 36 months in a supervised situation. For Neurologic MRI, at least 50 of the 300 cases shall have been MRA or the central nervous system. 8. Non-Nuclear medicine Licensed practitioner interpreting Cardiovascular Nuclear Medicine only: (Must meet one of the following criteria) Must be Board Certified in Cardiology by either the American Board of Internal Medicine, Royal College of Physicians and Surgeons of Canada (RCPSC), or Le College des Medicins du Quebec, and provide a letter from the program director and person responsible for the nuclear cardiology training showing completion of the Level 2 Core Cardiology Training Symposium (COCATS) training program in nuclear cardiology (see attachment 1). Cardiologist who trained prior to July 1995 must be Board certified in Cardiology and provide a letter from the program director and person responsible for the completion of the Level 2 training (see attachment 1). All other physicians must provide a letter from the program director and person responsible for the completion of the Level 2 training from a formal Accredited Council of Graduate Medical Education (ACGME) approved general nuclear medicine program (see attachment 2). 9. Non-Nuclear medicine Licensed practitioner interpreting Cardiovascular PET only: (Must meet one of the following criteria) Must be Board Certified in Cardiology by either the American Board of Internal Medicine, Royal College of Physicians and Surgeons of Canada (RCPSC), or Le College des Medicins du Quebec, and provide a letter from the program director and person responsible for the nuclear cardiology training showing completion of the Level 2 Core Cardiology Training Symposium (COCATS) training program in nuclear cardiology (see attachment 1). Cardiologist who trained prior to July 1995 must be Board certified in Cardiology and provide a letter from the program director and person responsible for the completion of the Level 2 training (see attachment 1). All other physicians must provide a letter from the program director and person responsible for the completion of the Level 2 training from a formal Accredited Council of Graduate Medical Education (ACGME) approved general nuclear medicine program (see attachment 2). 10. If not Board certified, licensed practitioner must be within one year following completion of a residency or fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME), with plans for completing the board examination within one year of the date of application.

8 11. Depending upon responses given on the credentialing application, a more detailed analysis of the applicant s training and experience may be required. If this is necessary, the Credentialing Committee may grant approval, pending receipt and review of the required materials. 12. Each licensed practitioner must posses a current medical license to practice medicine in the state where practice state where services are to be rendered. 13. Must provide proof of current professional liability insurance coverage. 14. Must provide proof of current facility general liability insurance coverage. 15. Foreign medical school graduates must submit an Educational Commission for Foreign Medical Graduates (ECFMG) Certificate. 16. Provide disclosure of malpractice history for the preceding 5 years. 17. Provide disclosure of any disciplinary issues or reportable actions to the NPDB or state medical board, or any sanction against the applicant s ability to possess a current Drug Enforcement Administration (DEA) Certificate or State level Controlled Dangerous Substance (CDS) Certificate. 18. Applicants who are not radiologists will be required, each time credentialed, to provide CME hours and volumes as listed in the charts below. CT specific CME: 50 hours in the past 36 MR specific CME: 50 hours in the past 36 PET specific CME: 20 hours in the past 36 NM specific CME : 15 hours in the past 36 CT Volume: Qualified Licensed practitioners must interpret at least 300 CT exams in the past 36 months. MR Volume: Qualified Licensed practitioners must interpret at least 300 MR exams in the past 36 months. PET Volume: Qualified Licensed practitioners must interpret at least 30 Brain Exams, 80 Oncologic Exams, 20 Cardiac Exams in the NM Volume: Qualified Licensed practitioners must interpret at least 15 scans per month in the past 24 months.

9 Network Physician Credentialing Standards (ATTACHMENT 1) Fellows who wish to practice the specialty of clinical nuclear cardiology should be required to have at least 4 to 6 months of total training. In training institutions with a high volume of nuclear cardiology procedures, clinical experience may be acquired in a period of time as short as 4 months. In institutions with a lower volume of procedures, a total of 6 months of clinical experience will be necessary for level 2 competencies. This additional training should be dedicated to enhancing clinical skills and qualifying for Nuclear Regulatory Commission (NRC) licensure. Didactic program Appropriate radiation safety training (currently 200 hours) should be provided to satisfy NRC licensure requirements. The training should provide fellows with a series of lectures and laboratories dealing with basic radiation physics, radiation protection, radiopharmaceutical chemistry, radiation biology and instrumentation according to NRC requirements. This program might be scheduled over a 12 to 24 month period concurrent with other fellowship assignments. Clinical experience The fellow should participate in interpretation of all nuclear cardiology imaging data for the 4 to 6 month training period. During the course of the 4 to 6 month training period, it is imperative that the fellow have experience in correlating catheterization /angiographic data with radionuclide-derived data in a minimum of 30 patients. A teaching conference in which the fellow presents the clinical material and scintigraphic results is an appropriate forum for such an experience. Another appropriate source of interpretative experience can consist of an established teaching file. For lever 2 raining, a total of 300 cases should be interpreted under supervision, either from direct patient studies or from the teaching file, consisting of diverse types of procedures. Minutes or a written logbook should be kept; cases and diagnoses should also be listed to provide documentation. Hands-on experience Fellows acquiring level 2 training should have additional hands-on experience with patient studies. Additional intensive experience should be acquired in a minimum of 50 patients; optimally 25 patients for myocardial (perfusion) imaging and 25 patients for radionuclide angiography (total 50 patients). Such supervised experience should include pretest patient evaluation, radiopharmaceutical preparation (including experience with relevant radionuclide generators), performance of the study (rest, exercise dipyridamole or adenosine or other pharmacologic stress), administration of dosage, calibration and set up of gamma camera, set up of imaging computer and processing the data for display after acquisition. Additional experience Evaluation In addition, the training program must provide experience in computer methods for analysis of perfusion imaging studies, including singleproton emission computer tomography (SPECT), and ejection fraction and regional wall motion measurements from radionuclide angiographic studies. Both the person responsible for the nuclear cardiology training program and the program director should also be responsible for evaluating the competence of the trainee in nuclear cardiology at the completion of the program. This can be accomplished by observing the performance of the fellow during the daily reading sessions or by formal testing procedure, or both. Reference:

10 Network Physician Credentialing Standards (ATTACHMENT 2) Non-Radiologist Physicians: At a minimum, completion of a formal Accreditation Council of Graduate Medical Education (ACGME) approved general nuclear medicine program which must include 200 hours in radiation physics and 500 hours of preparation in instrumentation, radiochemistry, radiopharmacology, radiation dosemitry, radiation biology, radiation safety and protection, and quality control. In addition, 1,000 hours of clinical training in general nuclear medicine is required which must cover technical performance, calculation dosages, evaluation of images, correlation with other diagnostic modalities, and interpretation. Reference: