ANCILLARY/FACILITY APPLICATION CREDENTIALING / RE-CREDENTIALING Please attach copies of all applicable documents to the application: Copy of all Federal, State and/or local licenses required to operate as a health care facility Copy of Facility s General Liability insurance certificate Copy of Professional (Malpractice) insurance certificate covering facility employees Copy of all Accreditation certificate(s) Copy of most recent CMS or Department of Health survey (including corrective action plan if deficiencies were cited along with evidence that all deficiencies have been corrected) Copy of current Medical Staff Roster Copy of W-9(s) Please note: Applications will not be processed until all required documentation is received. All incomplete applications will be returned after 6 months. GENERAL INFORMATION: Legal Business Name Doing Business As (DBA) Name Health System Affiliation (if applicable) NPI # Tax ID# - - - - Contact Name Phone Number Fax Number Title _ Email SERVICE LOCATIONS: Please indicate all service locations and a correspondence address. Attach a separate sheet if Location 1 more than two. Location 2 type: Service Correspondence Facility Name type: Service Correspondence Facility Name City, State Zip Code City, State Zip Code - - Phone Number Website - - Phone Number Website Please list all states and counties serviced. Please list all facilities with which coverage arrangements are in place. Name Specialty Name Specialty Ancillary/Facility 2015 1 of 5
BILLING / CREDENTIALING LOCATIONS: Billing Location Credentialing Location _ Entity Name Entity Name _ Contact Person Contact Person City, State Zip Code City, State Zip Code - - - - - - - - Phone Number Fax Number Phone Number Fax Number Email _ Email TAX ID: Please list all tax ID numbers that claims will be submitted under. - - - - TIN 1 TIN 2 TIN 3 TIN 4 PROFESSIONAL LIABILITY INSURANCE: Please attach Liability Insurance Face Sheet/Declaration Page. If ancillary/facility is self-insured, attach an actuarial analysis of the financial stability of the plan. Current Carrier Policy Number / / / / $ $ Effective Date Expiration Date Per Incident Aggregate During the past three years, has the facility ever been denied coverage (either initial or renewal) by any professional liability insurance carrier? If yes, please explain. During the past three years, has the facility had any malpractice judgments against it, made any settlements or have any pending cases against it? If yes, please provide background information on all cases and settlements on a separate sheet of paper, including the state, court and jurisdiction of any claims. It should be noted that involvement in professional liability actions and/or settlements does not disqualify facility from participation. The information is sought as part of the overall credentialing process. GENERAL LIABILITY INSURANCE INFORMATION: Current Carrier Policy Number / / / / $ $ Effective Date Expiration Date Per Incident Aggregate LICENSE NUMBERS: Please list all license(s) current and/or previously held for all states. _ / / / / License Number State Exp Date License Number State Exp Date / / /_/ Medicare Number Exp Date Medicaid Number State Exp Date Ancillary/Facility 2015 2 of 5
ACCREDITATION: Please indicate all current certifications/accreditations for the ancillary/facility and attach copies of certificates: AAAASF American Association for Accreditation of Ambulatory Surgery Facilities AAAHC Accreditation Association for Ambulatory Health Care AAOP American Academy of Orthotics and Prosthetics AASM American Academy of Sleep Medicine ABCOP American Board for Certification in Orthotics and Prosthetics ACR American College of Radiology AOPA American Orthotics and Prosthetic Association CAAS Commission on Accreditation of Ambulance Services CARF Commission on Accreditation of Rehabilitation Facilities CHAPS Community Health Accreditation Program CLIA Clinical Laboratory Improvement Amendments COLA Clinical Laboratory Accreditation ICANL Intersocietal Commission for Accreditation of Nuclear Medicine Laboratories JCAHO Joint Commission on Accreditation of Healthcare Organizations NCOPE National Commission on Orthotics and Prosthetic Education Other _ SERVICES PROVIDED: Please indicate the services and attach copies of documentation describing the ancillary/facility and services provided. Acute Care Hospital Ambulatory Surgery Office based surgical suite Diagnostic Imaging X-ray equipment MRI CAT PET Diagnostic ultrasound Cardiac testing other than routine EKG Durable Medical Equipment Endoscopy Dialysis Home Health Care Hospice Infusion Therapy Please list any non-english language proficiency: Laboratory Mammography Medical Transport Services Orthotics & Prosthetics Rehabilitation Certified Hand Therapy Physical Therapy Occupational Therapy Speech Therapy Substance Abuse Counseling (Inpatient only) Skilled Nursing Sleep Studies Physician: Staff: Is private parking available for patients? Is adequate seating available for patients? Are entrances, restrooms and parking handicap accessible? Does the ancillary/facility provide operating rooms? If so, how many? If one, please provide the NJ State letter for exemption or a site visit will be conducted by a CHN PPO staff member. Are anesthesiologists employed by this facility? Please attach a list names and addresses of anesthesiologists. Does this facility have recovery room beds? How many recovery room beds are there? List staff ratio: _ How often is the crash cart checked? Date of last inspection: Ancillary/Facility 2015 3 of 5
Please list the equipment in place for the various tests performed: Describe the maintenance schedule of the equipment. For radiology services only: Is equipment licensed by the appropriate authority? Is there a policy and procedure manual? Are X-ray badges worn by personnel and monitored? Are protective aprons utilized by both technicians and patients? Are there signs warning women of potential danger if they are pregnant? Who interprets the results of the X-rays? OWNERSHIP DISCLOSURE: Name of Organization: If a corporation, in which state incorporated and date: Please attach a list of names, titles and addresses of all Principles of Provider and indicate percent of ownership, if applicable. Principle means any shareholder, officer, director, partner, joint venture or anyone else having an ownership in or managerial control over Provider. QUALITY CONTROL: Describe the Quality Control program: Does the ancillary/facility participate in patient satisfaction surveys? Is the survey conducted by the ancillary/facility or by an outside contracted agency? Identify the contracted agency:_ How often are the surveys tabulated and reported? _ Who receives the reports? _ What concerns were identified in the most recent report? What actions are being taken to address those concerns? Ancillary/Facility 2015 4 of 5
CONDITIONS OF APPLICATION: By applying for appointment as a Participating Facility of CHN PPO, the undersigned Facility by its duly authorized agents does hereby: acknowledge that Facility has no right under the law to have this Application processed by CHN PPO or to become a Participating Provider in the CHN PPO Network; acknowledge that submission of this Application is not an assurance of my acceptance as a Participating Facility of CHN PPO and if Facility is not accepted it is not a reflection of the quality of Facility and CHN PPO will notify Facility in writing; acknowledge that Facility is required, as an applicant for membership in CHN PPO, to produce adequate information, within the time period established by CHN PPO, for a proper evaluation of Facility s professional, ethical and other qualifications for membership and for resolving any doubts about such qualifications to the satisfaction of CHN PPO; affirm that Facility shall provide for continuous care of it s patients, and refrain from delegating the responsibility for any aspect of the care of patients to any practioner or other person or facility not qualified to undertake that responsibility; authorize CHN PPO, its Medical Director and their representatives, in their sole discretion, to consult with prior and current associates and others who may have information bearing on Facility s competence, ethical qualifications, and other qualifications to be and continue to be a Participating Facility in CHN PPO; consent to the inspection by CHN PPO, its Medical Director and their representatives of all documents that may be material, in their sole discretion, to an evaluation of Facility s competence and consent to the release of such information. Facility hereby release from liability CHN PPO, its officers, directors, employees and agents for their acts performed and statements made, in good faith and without malice, in connection with evaluating the application of Facility, credentials and qualifications. In addition, Facility hereby releases any and all individuals and organizations who provide information to CHN PPO, its Medical Director and their representatives, in good faith and without malice, concerning the professional competence, and other qualifications of Facility to be a Participating Facility in CHN PPO. Facility hereby acknowledges that this release from liability is an express condition to Facility s application for, and acceptance of, membership in CHN PPO and Facility s continuation as a Participating Facility in CHN PPO; consent to the disclosure by CHN PPO, within its sole discretion, of the contents of this Application, the information contained in Facility s credentialing file and the credentialing and/or re-credentialing decisions of CHN PPO (together "Credentialing Information") to (i) independent credentialing entities; (ii) independent accreditation entities; (iii) other entities seeking to lease the CHN PPO network of Participating Providers and Facilities; (iv) participants in a review or appeal procedure, if any; and (together (i), (ii), (iii), and (iv) shall be "Authorized Recipients"). Facility hereby releases from liability CHN PPO, its officers, directors, employees and agents for their good faith disclosure of the Confidential Information to Authorized Recipients. Facility hereby acknowledges that this release from liability is an express condition to Facility s application for, and acceptance of, membership in CHN PPO and Facility s continuation as a Participating Facility in CHN PPO; agree to provide it s officers to meet with CHN PPO representatives in regard to this Application, if necessary; acknowledge that any material misstatements in or omissions from this Application constitute cause for denial of membership in CHN PPO or cause for summary dismissal from CHN PPO; recognize that the application process is a continuous process, that CHN PPO will credential and continuously re-credential Facility and that the authorizations, acknowledgements, consents and releases provided in this Application will remain in effect for purposes of credentialing and re-credentialing until revoked by Facility in writing; and All information submitted by Facility in this Application is true and complete to the best of my knowledge and belief. A photo static copy of this original statement constitutes Facility s written authorization and request to release any and all documentation relevant to this Application. Such photo static copy shall have the same force and effect as the signed original. SIGNATURE OF OWNER OR AUTHORIZED INDIVIDUAL DATE PRINT NAME DATE PLEASE PRINT NAME OF FACILITY www.chn.com CHN PPO A Division of Consolidated Services Group, Inc. PO Box 3382 Hamilton, NJ 08619-9917 (800) 225-4246 Ancillary/Facility 2015 5 of 5