Optum 1 Application for Provider Participation - Hawai i

Optum 1 Application for Provider Participation - Hawai i A. Personal Information Last Name First Name Middle Name Suffix (Jr., III, etc.) List any other names used: Other Last Name Other First Name Other Middle Name Suffix (Jr., III, etc.) Home Address Number/Street City State Zip Code Gender: Male Female Date of Birth: (mm/dd/yyyy) City of Birth State of Birth Country of Birth Social Security #: Do you treat members in your private home office? Ethnicity (used to meet patient referral requests): National Provider Identifier Number (NPI): B. Practice Information Are you accepting new patients? List all non-english languages you speak and write fluently: List all non-english languages your office personnel speak and write fluently: Are you a participating Medicaid provider? Medicaid #: Are you a participating Medicare provider? Medicare #: UPIN Number: Are your offices accessible for disabled persons? Please describe your arrangements for emergency coverage 24 hours per day, seven days a week: C. Primary Clinic/Office Information Name of Group/Clinic/Office Federal Tax ID Number for this practice County Phone Secure Fax E-mail Office Hours: For Tricare Telepsychiatry Services only, indicate if site is: Distant site and/or Originating Site 1 United Behavioral Health, operating under the brand Optum Rev. 7/9/13 1 BNSCom060712

D. Secondary Office Information Name of Group/Clinic/Office Federal Tax ID Number for this practice County Phone Secure Fax E-mail Office Hours: For Tricare Telepsychiatry Services only, indicate if site is: Distant site and/or Originating Site E. Billing Information Name of Group/Clinic/Office Phone Contact Name Contact Phone Number Attach a separate sheet for additional office locations F. License Information (List ALL current licenses and any others held in the past 5 years) State License Type License Number Date First Issued Expiration Date State License Type License Number Date First Issued Expiration Date State License Type License Number Date First Issued Expiration Date G. State Controlled Substance Permits State Permit Type Permit Number Date Issued Expiration Date State Permit Type Permit Number Date Issued Expiration Date H. DEA Federal DEA Number Date Issued Expiration Date I. Professional Degree of Medical Education (must be completed by all clinicians) Name of College or University Type of Program/Training Phone Number Major Degree Awarded Dates attended (mm/yy mm/yy) ECFMG Number (if applicable): (Educational Commission for Foreign Medical Graduates) Graduation Date (mm/yy) Attach copy of ECFMG certification Rev. 7/9/13 2 BNSCom060712

J. Additional Training (Internship, Residency, Fellowship, etc.) Name of College or University Your name as it appears on your diploma Degree Awarded Dates attended (mm/yy mm/yy) Graduation Date (mm/yy) Name of College or University Your name as it appears on your diploma Degree Awarded Dates attended (mm/yy mm/yy) Graduation Date (mm/yy) Name of College or University Your name as it appears on your diploma Degree Awarded Dates attended (mm/yy mm/yy) Graduation Date (mm/yy) K. Physicians Did you successfully complete an ACGME approved psychiatry residency? L. Board Certification or National Certification Date Originally Certified Name of Board Specialty of Certification Recertification Required? Date Certification Expires Date Originally Certified Name of Board Specialty of Certification Recertification Required? Date Certification Expires Date Originally Certified Name of Board Specialty of Certification Recertification Required? M.Current Hospital Admitting Privileges Date Certification Expires Name of Hospital Type of Privileges Phone Name of Hospital Type of Privileges Phone Rev. 7/9/13 3 BNSCom060712

N. Professional Liability Insurance (Clinician must be named as insured on the policy or attachment) Name of Carrier Policy Number Coverage Limits (Occurrence/Aggregate) Date Issued Expiration Date List any exclusions or limitations: O. Work History Please provide a chronological work history for the past 5 years, including employment, self-employment, clinical practice, service as an independent contractor, and military service. It is not necessary to duplicate education, internship, residency or fellowship information previously reported. Please explain any gaps in work history greater than 6 months. A Curriculum Vitae may not be substituted for completion of this section. Current Practice/Employer Name (must match practice info on page 2) Start Date (mm/yyyy) End Date (mm/yyyy) City State Title of Professional Occupation Previous Practice/Employer Name Start Date (mm/yyyy) End Date (mm/yyyy) City State Title of Professional Occupation Previous Practice/Employer Name Start Date (mm/yyyy) End Date (mm/yyyy) City State Title of Professional Occupation Previous Practice/Employer Name Start Date (mm/yyyy) End Date (mm/yyyy) City State Title of Professional Occupation Previous Practice/Employer Name Start Date (mm/yyyy) End Date (mm/yyyy) City State Title of Professional Occupation Please provide an explanation for any gaps in work history greater than 6 months: Gap Dates: Explanation: (mm/yyyy to mm/yyyy) Gap Dates: Explanation: (mm/yyyy to mm/yyyy) Rev. 7/9/13 4 BNSCom060712

P. Disclosure Questions Answer all questions. If your answer to any of the following questions is yes, you must provide a detailed explanation, including dates, allegations and outcomes. If legal proceedings or board actions were involved, you must attach a copy of the documents, including allegations, judgments and dismissals. 1. Have you ever been involved in a malpractice claim? Please attach a completed supplemental claim form for each 2. Has any monetary payment ever been made because of alleged medical malpractice? 3. Are there currently any pending medical malpractice claims or settlements? 4. Has your professional liability insurance coverage ever been denied, limited or cancelled by any carrier? 5. Have the following ever been investigated, denied, restricted, revoked, suspended, refused, reduced, excluded, debarred, censured, disqualified, terminated, limited, placed on probation, placed under other disciplinary action, including letter of admonishment or reprimand? a) Professional healthcare of medical license in any state? b) Other professional license and/or registration? c) DEA registration or state CDS/drug registration? d) Academic appointment? e) Membership and/or employment on any hospital medical staff? f) Clinical privileges/other rights on any medical staff? g) Other institutional affiliation or status including a managed care organization? h) Professional society membership or fellowship/board? i) Professional office? j) Participation in any private, state or federal insurance program including Medicare and Medicaid programs? k) Any other type of professional group? l) Medical employment in any clinic, group, HMO, hospital, etc.? 6. Have you ever voluntarily surrendered a professional license, membership, or participation in a professional organization as an alternative to disciplinary action or during an investigation into your professional competence or conduct? 7. Have you ever been charged or convicted of, pled guilty to, or pled nolo contendere to a misdemeanor (except minor traffic violations) or felony? 8. Have you ever been the object of an administrative, civil, or criminal complaint or investigation regarding sexual misconduct? 9. Have you ever been placed on probation in any training program or have you failed to satisfactorily complete any training program or portion of a training program? 10. Are you currently using any illegal substances or are you chemically dependent on alcohol, drugs, or illegal substances? 11. Is there any reason you cannot perform essential job-related functions competently, with or without reasonable accommodation, without risk to patient safety or health? Rev. 7/9/13 5 BNSCom060712

Q. Clinical Expertise Checklist Please check all areas in which you have training and experience and are currently willing to treat in your practice. Note: All clinicians are designated to do general therapy and treat depression, anxiety, and mood disorders. Clinicians in the credentialing or recredentialing process have the following rights: to review information submitted to support his/her (re)credentialing application to correct erroneous information obtained by Optum to evaluate his/her (re)credentialing application (not including references, recommendations and other peer-review protected information) to submit any corrections, in writing, within ten (10) days to obtain, upon request, information regarding the status of their application Abuse (Physical, Sexual, etc) Adoption Issues Anger Management Attention Deficit Disorders (ADHD) Bariatric/Gastric Bypass Evaluation Behavior Modification Biofeedback Certified Pastoral Counselor Christian Counseling Co-Occurring Disorders Treatment (Dual Diagnosis) Cognitive Behavioral Therapy Compulsive Gambling Crisis Diversionary Services Developmental Disabilities Dialectical Behavioral Therapy Dissociative Disorders Domestic Violence Electro-Convulsive Therapy (ECT) Eye Movement Desensitization & Reprocessing (EMDR) Forensic Gay/Lesbian Issues Gay/Lesbian Identified Clinician Grief/Bereavement Hearing Impaired Populations HIV/AIDS/ARC Home Care/Home Visits Populations Treated (check all that apply) Adult Couples/Marriage Therapy Family Therapy Hypnosis Independent/Qualified Medical Examiner Infertility Learning Disabilities Medical Illness/Disease Management Medication Management (Prescribers ONLY) Military/Veterans Treatment Nursing Home Visits Obsessive Compulsive Disorder Organic Disorders Pain Management Personality Disorders Phobia Police/Fire Fighters Post-Partum Depression Post Traumatic Stress Disorder Psych Testing Psychotic/Schizophrenic Disorders Rape Issues Sex Offender Treatment Sexual Dysfunction Sleep Disorders Somatoform Disorders Transgender Weapons Clearance Group Therapy Inpatient Rev. 7/9/13 6 BNSCom060712

R. Optum Specialty Attestation Additional training, experience and/or outside agency approval for the following populations, professional certifications, and specialties is required. Please review the attached Specialty Requirements. If documentation requested below for a specific specialty is not submitted, that specialty will not be designated in your record. If you are not requesting a specialty designation, please check the No Specialties box at the bottom of the list to indicate you have read this form and acknowledge that you have not requested these specialties. Your signature on this application serves as attestation that you have reviewed the Optum Specialty Requirements criteria that a Clinician must meet to be considered a specialist in the following treatment areas (final pages of this document). After reviewing the criteria, your signature serves as attestation that, by placing a check next to a specialty or specialties, you meet Optum requirements for that treatment area. Infant Mental Health (0-3 years) Preschool (0-5 years) Children (6-12 years) Adolescents (13-18 years) Geriatrics Autism Spectrum Disorders (ASD) Certification by American Board of Examiners in Clinical Social Work (current and in good standing) Chemical Dependency/Substance Abuse Certified Employee Assistance Professional (submit CEAP certificate) Critical Incident Stress Debriefing (submit CISD certificate) Disability Evaluation/Management (if checked, we will send you a Memorandum of Understanding for completion & submittal) Eating Disorders Employee Assistance Professional (EAP) Neuropsychological Testing Nurses Prescriptive Privileges (submit ANCC certificate, Prescriptive Authority, DEA certificate and/or State Controlled Substance certificate, based upon state requirement) Suboxone Treatment (submit DEA registration with the DATA 2000 prescribing identification number) Substance Abuse Expert (submit Nuclear Regulatory Commission qualification training certificate) Substance Abuse Professional (submit Department of Transportation certificate) Telepsychiatry Services Veterans Administration Mental Health Disability Examination (Psychologists only) Worker s Compensation No Specialties Please note that standard credentialing criteria must be met before specialty designation can be considered. All clinicians must sign this application whether specialties are applicable or not. Failure to sign this application may cause a delay in the processing of your initial credentialing file. I acknowledge that I have read the UBH Agreement, Network Manual, and the State Regulatory Attachment, Medicare Regulatory Attachment and/or Medicaid Regulatory Attachment. Rev. 7/9/13 7 BNSCom060712

S. Attestation and Authorization to Release Information By applying for participation in the Optum network, I hereby signify my willingness to appear for interviews in regard to my application. I authorize Optum and its representatives to consult with associates and others who may have information concerning my professional competence, character, health status, ethical qualifications, ability to work cooperatively with others and malpractice claims history. I release from liability all representatives of Optum and its Members and its representatives for their acts performed and statements made in good faith and without malice concerning my professional competence, ethics, character and other qualifications for participation. I authorize: the facilities with which I maintain privileges, am credentialed by or am a member of other health care institutions to which I belong other entities with which I am a provider all past and present professional liability insurance carriers government agencies, including licensing agencies to release to Optum information that is requested by Optum, including copying pertinent portions of my records. The information authorized for release includes but is not limited to: practice and quality assurance information status and scope of hospital privileges status and scope of membership, credentialing and privileges in all other health care institutions and entities claims history, certificate of insurance, complaints history I hereby release from liability all health care providers, facilities, practice groups, other entities or other persons, including past and present professional liability insurance carriers and their statements made, responses made to inquiries or documents released to Optum, provided or released in good faith and without malice concerning my professional competence, ethics, character and other qualifications for participation. I understand that Optum may require additional documentation to verify that I meet the criteria outlined under Specialty Requirements pertaining to the specialty or specialties I have designated above. I will cooperate with an Optum documentation audit, if requested, to verify that I meet the required criteria. I hereby attest that all of the information above is true and accurate to the best of my knowledge. I understand that any information provided pursuant to this attestation that is subsequently found to be untrue and/or incorrect could result in my termination from the Optum network. I agree that photocopies of this document are as binding as the original. Signature of Applicant: Typed or Printed Name: Date: Rev. 7/9/13 8 BNSCom060712

PHYSICIAN SPECIALTY REQUIREMENTS Important Note: Signature on the above Specialty Attestation page is required of all applicants INFANT MENTAL HEALTH: Completion of an ACGME approved Child Fellowship OR recognized certification in Child Psychiatry And one (1) or more of the following: Ten (10) hours of CME in infant mental health/early childhood development in the last twenty-four (24) month period Evidence of at least twenty-five percent (25%) of practice experience in the treatment of infant mental health PRESCHOOL/CHILDREN: Completion of an ACGME approved Child Fellowship OR recognized certification in Child Psychiatry Ten (10) hours of CME in preschool/children in the last twenty-four (24) month period Evidence of at least twenty-five percent (25%) of practice experience in the treatment of preschool/children ADOLESCENTS: Completion of an ACGME approved Child and Adolescent Fellowship OR recognized certification in Adolescent Psychiatry Ten (10) hours of CME in adolescents in the last twenty-four (24) month period Evidence of at least twenty-five percent (25%) of practice experience in treating adolescent patients GERIATRICS: Completion of an ACGME approved Geriatric Fellowship OR recognized certification in Geriatric Psychiatry Ten (10) hours of CME in Geriatrics in the last twenty-four (24) month period Evidence of at least twenty-five percent (25%) of practice experience in treating geriatric patients AUTISM SPECTRUM DISORDERS: Six (6) months full-time clinical work in an ASD clinic or structured ASD setting within past five (5) years OR Twenty percent (20%) of current practice involved in the assessment and treatment of patients with ASD CHEMICAL DEPENDENCY/SUBSTANCE ABUSE: Completion of an ACGME approved fellowship in Addiction Medicine OR Certification in Addiction Medicine or ASAM Ten (10) hours of CME in Substance Abuse in the last twenty-four (24) month period Evidence of at least twenty-five percent (25%) of practice experience in SA treatment DISABILITY: Experience or training in performing functional capacity evaluations for disability or worker s compensation, or as a qualified independent medical examiner. Thorough review of the Disability Solutions Psychiatric Disability Management Program Clinician Manual and signed Memorandum of Understanding in agreement with our Disability Solutions protocols EATING DISORDERS: One (1) year fellowship, internship or practice in Eating Disorders, completed at an accredited institution or approved program AND Evidence of at least one (1) year professional experience with at least twenty-five percent (25%) of practice in the treatment of eating disorders Ten (10) hours of CME in Eating Disorders in the last twenty-four (24) month period NEUROPSYCHOLOGICAL TESTING: Recognized certification in Neurology through the American Board of Psychiatry and Neurology OR Accreditation in Behavioral Neurology and Neuropsychiatry through the American Neuropsychiatric Association AND all of the following criteria: State medical licensure specifically allows for provision of neuropsychological testing service; Evidence of professional training and expertise in the specific tests and/or assessment measures for which authorization is requested; Physician and supervised psychometrician adhere to the prevailing national professional and ethical standards regarding test administration, scoring, and interpretation. SUBOXONE TREATMENT: DEA registration certificate with the DATA 2000 prescribing identification number SUBSTANCE ABUSE EXPERT (SAE) Nuclear Regulatory Commission (NRC): Certificate of NRC SAE qualification training (agencies providing such certification include, but are not limited to, ASAP, Inc, Program Services, and SAPAA) TELEPSYCHIATRY SERVICES A qualified practitioner at a distant site must be licensed in the state where the member resides, and deliver services in a manner that is consistent with the Health Insurance Portability and Accountability Act (HIPAA) and other applicable privacy and security regulations and standards AND An interactive telecommunication system must be used and include auditory and visual equipment and transmittal mechanism to facilitate the secure two-way, real-time interaction between the member at a qualifying originating site and a distant site practitioner WORKER S COMPENSATION: Twenty-four (24) months experience assessing and treating worker s compensation cases Rev. 7/9/13 9 BNSCom060712

PSYCHOLOGISTS & MASTER S LEVEL CLINICIANS SPECIALTY REQUIREMENTS Important Note: Signature on the above Specialty Attestation page is required of all applicants INFANT MENTAL HEALTH: Completion of an APA approved or other accepted training/certification program in Child Psychology or Infant Mental Health And one(1) or more of the following: Ten (10) hours of CEU in infant mental health/early childhood development in the last twenty-four (24) month period Evidence of at least twenty-five percent (25%) of practice experience in the treatment of infant mental health PRESCHOOL/CHILDREN: Completion of an APA approved or other accepted training program in Child Psychology Ten (10) hours of CEU in preschool/children in the last twenty-four (24) month period Evidence of at least twenty-five percent (25%) of practice experience in the treatment of preschool/children ADOLESCENTS: Completion of an APA approved or other accepted training program in Adolescent Psychology Ten (10) hours of CEU in adolescents in the last twenty-four (24) month period Evidence of at least twenty-five percent (25%) of practice experience in treating adolescent patients GERIATRICS: Completion of an APA approved or other accepted training program in Geriatric Psychology Ten (10) hours of CEU in Geriatrics/Gerontology in the last twenty-four (24) month period Evidence of twenty-five percent (25%) of practice experience in treating geriatric patients AUTISM SPECTRUM DISORDERS: Six (6) months full-time clinical work in an ASD clinic or structured ASD setting within past five (5) years OR Twenty percent (20%) of current practice involved in the assessment and treatment of patients with ASD CERTIFICATION BY AMERICAN BOARD OF EXAMINERS IN CLINICAL SOCIAL WORK Certification must be current and in good standing CHEMICAL DEPENDENCY/SUBSTANCE ABUSE: Completion an APA or other accepted training in Addictionology OR Certification in Addiction Counseling Ten (10) hours of CEU in Substance Abuse in the last twenty-four (24) month period Evidence of twenty-five percent (25%) practice experience in substance abuse CERTIFIED EMPLOYEE ASSISTANCE PROFESSIONAL (CEAP): Certificate from the Employee Assistance Certification Commission CRITICAL INCIDENT STRESS DEBRIEFING: Certificate of CISD training from American Red Cross or Mitchell model Documentation of training and CEU units in the provision of CISD services DISABILITY: Experience or training in performing functional capacity evaluations for disability or worker s compensation OR Experience or training in at least two (2) of these four (4) categories: EAP counseling, managing stress in the workplace, comorbid medical conditions or substance abuse AND Thorough review of the Disability Solutions Psychiatric Disability Management Program Clinician Manual and signed Memorandum of Understanding in agreement with our Disability Solutions protocols EMPLOYEE ASSISTANCE PROFESSIONAL (EAP): Minimum of two (2) years experience in the delivery of EAP core technology as defined by EAPA, and Minimum of one (1) annual training (CEU credits or professional development hours) in any of the six (6) EAP content areas Rev. 7/9/13 10 BNSCom060712

PSYCHOLOGISTS & MASTER S LEVEL CLINICIANS SPECIALTY REQUIREMENTS (cont.) EATING DISORDERS: One (1) year fellowship, internship or practice in Eating Disorders, completed at an accredited institution or approved program AND Evidence of at least one (1) year professional experience with at least twenty-five percent (25%) of practice in the treatment of eating disorders Ten (10) hours of CEU in Eating Disorders in the last twenty-four (24) month period NEUROPSYCHOLOGICAL TESTING Psychologist Only: Member of the American Board of Clinical Neuropsychology OR the American Board of Professional Neuropsychology OR Completion of courses in Neuropsychology including: Neuroanatomy, Neuropsychological testing, Neuropathology, or Neuropharmacology Completion of an internship, fellowship, or practicum in Neuropsychological Assessment at an accredited institution AND Two (2) years of supervised professional experience in Neuropsychological Assessment SUBSTANCE ABUSE EXPERT (SAE) - Nuclear Regulatory Commission (NRC): To qualify as an SAE for the NRC, you must possess one of the following credentials: Licensed or certified social worker Licensed or certified psychologist Licensed or certified employee assistance professional Certified alcohol and drug abuse counselor - The NRC recognizes alcohol and drug abuse certification by the National Association of Alcoholism and Drug Abuse Counselors Certification Commission (NAADAC) or by the International Certification Reciprocity Consortium/Alcohol and Other Drug Abuse (ICRC/AODA). AND Certificate of NRC SAE qualification training (agencies providing such certification include, but are not limited to, ASAP, Inc., Program Services, and SAPAA) SUBSTANCE ABUSE PROFESSIONAL (SAP): Certificate of training in federal Department of Transportation SAP functions and regulatory requirements (agencies providing such certification include, but not limited to, Blair and Burke, EAPA and NMDAC) TELEPSYCHIATRY SERVICES A qualified practitioner at a distant site must be licensed in the state where the member resides, and deliver services in a manner that is consistent with the Health Insurance Portability and Accountability Act (HIPAA) and other applicable privacy and security regulations and standards AND An interactive telecommunication system must be used and include auditory and visual equipment and transmittal mechanism to facilitate the secure two-way, real-time interaction between the member at a qualifying originating site and a distant site practitioner VETERANS ADMINISTRATION MENTAL HEALTH DISABILITY EXAMINATION Psychologist Only: Graduate of an American Psychological Association accredited university (qualification counts even if accreditation occurred after date of graduation) Wheelchair accessible office PC user (Macintosh/Mac computers do not interface with the testing software used in the Disability Examination) Agree to participate in initial and annual training programs as required by LHI Agree to offer appointments within 10 to 14 days of the request for services Agree that beneficiary will not wait longer than 20 minutes in the office before being tested WORKER S COMPENSATION: Twenty-four (24) months experience assessing and treating worker s compensation cases NURSES REQUESTING PRESCRIPTIVE AUTHORITY MUST: Possess a currently valid license as a Registered Nurse in the state(s) in which you practice Be authorized for prescriptive authority in the state in which you practice Meet state specific mandates for the state in which you practice regarding DEA license and physician supervision Attest that you meet your state s collaborative or supervisory agreement requirements Specifically request prescriptive privileges on the OptumHealth application above Rev. 7/9/13 11 BNSCom060712

IMPORTANT TAX DOCUMENT SUBSTITUTE FORM W-9 Request for Taxpayer Identification Number As part of the contracting process, we are requesting that you complete this Substitute Form W-9. We are required by law to obtain this information from you when making a reportable payment to you. If you do not provide us with this information, your payments may be subject to federal income tax backup withholding. Also, if you do not provide us with this information, you may be subject to a penalty imposed by the Internal Revenue Service under Section 6723 of the Internal Revenue Code. This information must be consistent with the data provided on Page 1 of the application (clinic information). 1. Taxpayer Name (To whom the check is payable) (A legal entity name if a corporation or partnership) Doing Business as: (A division name, if a corporation, or the name of the business, if a sole proprietor) DBA 2. Taxpayer Address 3. Taxpayer Identification Number a. Corporation b. Partnership c. Sole Proprietorship d. Tax Exempt Entity (List employer identification number) (List employer identification number) (List social security number or employer identification number) (List employer identification number) e. Other Please Explain 4. Effective Date of Taxpayer Name and TIN 5. Form Completed By 6. Signature (Print name) (Signature) 7. Today s Date 8. Daytime Phone Number ( ) PLEASE NOTE: INFORMATION REPORTED ON LINES 1-3 MUST BE CONSISTENT WITH DATA ON FILE WITH THE IRS AND SOCIAL SECURITY ADMINISTRATION. Rev. 7/9/13 12 BNSCom060712