INSTRUCTIONS: If your organization has multiple physical locations/businesses, include a separate full application for any facility grouping for which there is an independent facility survey and/or facility license. This application must be filled out in hand printed ink or typewritten copy with all questions answered. If a particular section (1-5) is not applicable to you, mark that section with an N/A. Section 6 must be completed by all applicants. The information listed below must accompany the completed application when applicable: State Medical Facility License(s)/Registration(s) (if applicable) DEA certificate(s) (for all practitioners, if facility DEA isn t applicable) Current Professional Liability Insurance face sheet (and any other Insurance face sheets for the facility) List of subcontracted company/facility services (if applicable) List of employed licensed healthcare providers (if applicable) W9 Form (TIN Number Identification) If you are not accredited by an accreditation organization recognized by Molina in Section 5 of this application (JC, AAAASF, AAAHC, ABCOP, ACHC, AOA-HFAP, ASHI, BOC, CAP, CARF, CHAP, COLA, DNV, HQAA, NABP,NBAOS, CABC, PPFA, The Compliance Team) you must also submit the following information, if applicable: A copy of the most recent State and/or CMS on-site survey results, including the corrective action plan (CAP) to any deficiencies, and a copy of the letter verifying acceptance of the CAP by CMS. Incomplete applications will be returned for completion prior to processing. Please return application and attachments to: Molina Healthcare of Washington Inc / ATTN Provider Services / PO Box 4004 / Bothell WA 98041-4004 1. ORGANIZATION INFORMATION: (Provide physical location information on the following page) Legal Name of Organization (Legal name listed with the IRS) DBA Name of Organization (if applicable) Organization Owner: Select All Appropriate Choice(s) Mailing Address Street Address: Organization Administrator: Privately owned City or County owned Select For profit Corporation Taxing District owned One Non-profit Billing Address (if different than Mailing) Street Address: Address Line 2: Address Line 2: City: State: Zip: City: State: Zip: Phone: Fax: Phone: Fax: Credentialing Contact Person: Phone #: Fax #: Email Address: Billing Contact Person: Phone #: Fax #: Revised: 03/21/11 Page 1 of 7
INCLUDE THE BELOW INFORMATION FOR EACH PRACTICE LOCATION ONLY include information for locations that you wish to be listed with Molina Healthcare 2. PHYSICAL LOCATION INFORMATION: (Include any additional information relevant to this location on a separate sheet) Specific Location DBA (if different than the Organization DBA) Is this location Medicare Certified? Is this the primary address? Site-specific Medicare #: Site-specific Medicaid #: Federal TIN: NPI #: Physical Practice Location Street Address: Address Line 2: City: State: Zip: LTC provider # (if applicable): Is this location wheelchair accessible? Describe your service area (States, Counties, Cities, etc.): Phone: Fax: Please list any languages spoken by office personnel: Practice Limitations (e.g., age, gender, etc.): Office Hours (open to close): Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: License(s) (Attach a copy of all licenses) Please check here if this location is not required to be licensed by an appropriate State agency. 1) State of Licensure: Date of Most Recent Licensure Survey: 2) State of Licensure: Date of Most Recent Licensure Survey: Type of Licensure: Type of Licensure: License Expiration Date: License Expiration Date: License Number: License Number: Registration(s), Certificate(s), etc (Attach a copy of all registrations, certificates, etc) DEA Number: Issue Date: Expiration Date: CSR/CDS Number: Issue Date: Expiration Date: CLIA Number: Issue Date: Expiration Date: Other Certificates/Registrations/Licenses: Revised: 03/22/11 Page 2 of 7
3. PRIMARY CONTRACTED SPECIALTY & TAXONOMY: (If each location offers different services, please indicate this on a separate sheet or attachment) (If there are multiple primary CONTRACTED specialties, check ALL that apply) Mental/Substance Rehabilitation Specialties Physical Rehabilitation Specialties Mental Health Clinic - Inpatient (323P00000X) Outpatient Rehab Facility - CORF (261QR0401X) Mental Health Clinic - Outpatient (261QM0801X) Rehabilitation Clinic - PT/OT/SLP (261QR0400X) Substance Abuse Clinic - Inpatient (324500000X) Occupational Therapy Clinic (no-grp-txnmy) Substance Abuse Clinic - Outpatient (261QR0405X) Physical Therapy Clinic (261QP2000X) Hospital Specialties Speech Therapy Clinic (no-grp-txnmy) General Acute Care (282N00000X) Medical Supplier Specialties (when credentialing necessary) Psychiatric (283Q00000X) Durable Medical Equipment (332B00000X) Rehabilitation (283X00000X) Respiratory DME Equipment (332BX2000X) Other Specialties Emergency Response Services (333300000X) Home Infusion Therapy (251F00000X) Minor Home Modifications (171WH0202X) Infusion Therapy Clinic (261QI0500X) Pharmacy (333600000X) Laboratory (291U00000X) Portable X-Ray Supplier (335V00000X) Laboratory - IDTF (293D00000X) Prosthetic/Orthotic Supplier (335E00000X) Custodial Care Specialties Ambulatory Specialties Assisted Living Facility (310400000X) Adult Day Care (261QA0600X) Adult Care Home (311ZA0620X) Ambulatory Surgery Center (261QA1903X) Adult Foster Care Agency (253J00000X) Birthing Center (261QB0400X) Day Training and Health Services (251C00000X) Dialysis (ESRD) Center (261QE0700X) Home Health Agency (251E00000X) Federally Qualified Health Center (261QF0400X) Hospice Facility (315D00000X) Radiology Clinic (261QR0200X) In Home Supportive Care / P.A.S. (253Z00000X) Radiology Clinic - Mobile (261QR0208X) Skilled Nursing Facility (314000000X) Urgent Care Clinic (261QU0200X) Other Specialty: Taxonomy (if applicable): Additional Notes on Specialty Designation: 4. CURRENT INSURANCE COVERAGE: (Please attach a copy of your current facility liability insurance face-sheet) Please check here if your facility is not insured. Current Carrier Name: Policy Start Date: Broker/Agent Name: Policy End Date: Policy Number: Policy Type (malpractice, general, etc.): Agency Phone Number: Type of Coverage: Occurrence based Claims based If claims based, does this facility have tail coverage? Coverage amount per occurrence: Coverage amount aggregate: Revised: 03/22/11 Page 3 of 7
Molina Healthcare of Washington, Inc. 5. ACCREDITATION / CERTIFICATION (continued on next page): (Please attach a copy of the most recent accreditation certificate for each accrediting body) Please check here if your facility is not accredited and not required to be Medicare certified. Medicare Certification The Joint Commission (CMS) (JC) Am Assoc for Accred of Ambulatory Surgery Fclts Accred Assoc for Ambulatory Health Care (AAAASF) (AAAHC) Am Board for Certification in Orthotics/Prosthetics Accred Commission for Health Care (ABCOP) (ACHC) AOA s Healthcare Facilities Accred Program Am Society for Hstcmptblty and Immunogenetics (AOA-HFAP) (ASHI) Board for Orhtoist/Prosthetist Certification College of American Pathologists (BOC) (CAP) Commission on Accred of Rehabilitation Facilities Community Health Accreditation Program (CARF) (CHAP) Revised: 03/22/11 Page 4 of 7
Molina Healthcare of Washington, Inc. 5. ACCREDITATION / CERTIFICATION (continued): (Please attach a copy of the most recent accreditation certificate for each accrediting body) Committee of Laboratory Accreditation (COLA) Det Norske Veritas (DNV) Healthcare Quality Association on Accreditation (HQAA) National Assoc of Boards of Pharmacy (NABP) National Board of Accred for Orthotics Suppliers (NBAOS) The Compliance Team Commission for the Accred of Birth Centers (CABC) Planned Parenthood Federation of America (PPFA) Molina ONLY recognizes accreditation by CMS Deemed bodies, with the exception of the CABC and PPFA. Revised: 03/22/11 Page 5 of 7
6. CREDENTIALING PROGRAM: 1) Do you verify the credentials of all licensed and non-licensed staff that you employ? For yes, please check method(s) of verification for Licensed staff: Online directly with the appropriate State Board Obtaining a current copy of the license Other: For yes, please check method(s) of verification for Non-Licensed staff: Background Check agency Previous employers Other: 2) Do you ensure that each of the licensed staff practicing at your facility renews his/her State License before it expires? 3) Do you perform Background Checks on all of your staff before hiring? For yes, please check all of the method(s) you utilize: Federal and/or State Criminal Background Check(s) Background Check agency Search a State Misconduct Registry or equivalent Other: 4) Has your facility or organization ever been sanctioned by any State or Federal body? (If yes, please provide a detailed explanation) 5) Have the owners or the employees of your facility ever been sanctioned by any State or Federal body? (If yes, please provide a detailed explanation) Revised: 03/22/11 Page 6 of 7
ATTESTATION AND RELEASE OF INFORMATION FORM Modifications Will Not Be Accepted RELEASE OF INFORMATION: As part of the application process and for the purpose of verifying any information provided on this application, I, the undersigned authorized agent of the applicant facility/organization, grant Molina Healthcare permission to contact any individual, institution, facility or agency identified on, or relative to, this application. Further, I herby consent and authorize Molina Healthcare to request, receive and inspect any and all record pertinent to consideration of this application. As a Molina Healthcare Plan facility/organization applicant, I, the undersigned authorized agent, am required to supply Molina Healthcare with verification of current malpractice coverage. SITE REVIEW AUTHORIZATATION: I herby grant permission for Molina Healthcare to conduct on-site and medical record reviews as necessary. I further agree that this facility will participate in and support Molina Healthcare s quality improvement and utilization review programs. ATTESTATION: I certify the information on this entire application is complete, accurate, and current. I acknowledge that any misstatements in or omissions from this application constitute for denial or summary dismissal. A copy of this application has the same force and effect as the original. I have reviewed this information as of the most recent date listed below. Further, I understand that acceptance of this application does not constitute approval or acceptance or participating status with Molina Healthcare and grants this facility no rights or privileges of participation until such time as a contract is consummated and written notice of participating status is issued to this facility by Molina Healthcare. I acknowledge that action on this application will be delayed until all required information is received and/or verified. This facility complies with all federal, state, and local handicapped access requirements as well as the standards required by the 1992 Federal Americans with Disabilities Act. Print Name Here: Signature: (Stamped signature is not acceptable) Date: Revised: 03/22/11 Page 7 of 7