provider credentialing application - align networks · (10/24/14) page 1 of 13 provider...

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Provider Credentialing Application

Key Contact Information (Please supply high level contacts for each of the following areas in your organization):

Contracting:

Name: ____________________ Phone: ______________________Email:____________________________

Clinical:

Name: ____________________ Phone: ______________________Email:____________________________ Billing:

Name: ____________________ Phone: ______________________Email:____________________________ Corporate:

Name: ____________________ Phone: ______________________Email:____________________________ Credentialing:

Name: ____________________ Phone: ______________________Email:____________________________ Scheduling:

Name: ____________________ Phone: ______________________Email:____________________________

Corporate/Main Office Information: Address: ________________________________________________________________________________

Phone Number: _______________ Fax Number: _______________ E-Mail Address: ___________________

Ownership and Management: Check all that apply: Corporation For Profit Not for profit

Partnership Sponsorship Hospital Sole Proprietorship Privately Held Other Organization

Facility/Provider Information - General Information: Facility/Provider Legal Name: ________________________________________________________________ Facility/Provider DBA (if applicable):____________________________________________________________ Facility/Provider Tax Identification #:______________ Medicare Provider # (if applicable): ________________ Group/Facility NPI #: _______________ What type of billing form is utilized by your facility/facilities? UB92/UB04 or HFCA/CMS1500 Pennsylvania Providers Only – Is your facility a PA – Part A or PA – Part B Provider?

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General Information (Continued):

Is your Organization a Physician-Owned Facility/Facilities? Yes No Is your Organization part of any networks? Yes No (If yes please specify): _______________________ What is your bill cycle: Daily Weekly Bi-Weekly Monthly Other (please specify): _________________ Day of week bills are generated: Mon Tues Wed Thurs Fri Sat Sun Number of Therapists in your organization that are members of APTA: __________ Number of Therapists in your organization that are members of AOTA: __________ Owner Information (*) Are you a Women Owned and Operated Provider (Women’s Business Enterprise)? Yes No Are you a Minority Owned and Operated Provider (Minority Business Enterprise)? Yes No (*) Answers to these questions are optional and are included for compliance with Federal Data Collections.

Payment Address: (Please provide the following information regarding where your organization’s payments are to be mailed)

Address: ________________________________________________________________________________ Phone Number:_______________________ Fax Number: __________ E-Mail Address: _______________ Contact Person Name & Title: _______________________________________________________________ Phone # for Contact Person: ____________________ Fax Number for Contact Person: __________________

Professional Liability Insurance Coverage- Malpractice Information

Self-Insured: Yes No Name of Current Malpractice Insurance Carrier or Self-Insured Entity: ________________________________ Address:_________________________________________________________________________________ Phone Number: ___________________ Policy Number: __________________________________________ Effective Date (MM/DD/YY):_________________ Expiration Date (MM/DD/YY):__________________________ Amount of Coverage Per Occurrence: _______________ Amount of Coverage Aggregate: _______________ Type of Coverage: Individual Shared

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Professional Liability Insurance Coverage- Malpractice Information (Continued):

Length of Time with Carrier: ___________________ Has your facility/facilities had any claims, suits or settlements in the last 5 years? Yes No (If yes, attach details for each claim) To your organization’s knowledge, are there any claims that have not been filed; however, you have been notified of the intent to file? Yes No (If yes, attach details for each claim) * Copy of Insurance Coversheet Required.

Medicare/Medicaid Provider Information: Is your organization an approved Medicare Provider? Yes No Medicare Provider #:______________ Is your organization an approved Medicaid Provider? Yes No Medicaid Provider #_______________ Number of Practitioners within the organization with individual Medicare/Medicaid Provider Numbers:_______ *Please include a copy of CMS Certificate for all active Medicare/Medicaid Provider Numbers within your organization

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Please complete one copy of

page 5 for

EACH TREATING LOCATION.

Make additional copies as needed. Applications submitted without fully

completing page 5 for each active treating location will be declined.

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Individual Treating Location Information ONE COPY OF THIS PAGE MUST BE COMPLETED FOR EACH TREATING LOCATION (Please provide the following information regarding your treating location/locations – please make copies if necessary.)

Location Name: ___________________________________________________________________________ Address: ________________________________________________________________________________ Phone Number: _____________ Fax Number: _____________ E-Mail Address: ________________________ Office Manager Name: _________________________ Office Manager Phone Number: __________________ Office Manager Fax Number: _____________ Office Manager E-Mail Address: _________________________ Services provided (please check all applicable): PT OT DC Aquatic EMG FCE WH

WC CHT X-RAY MRI Speech Whirlpool Splinting Wound Care Debridement

Vestibular Rehabilitation Lymphedema Acupuncture Massage Job Site Assessment

Ergonomic Assessment CARF Certification (provide copy of certification)

Is this location Spanish Speaking? Yes No If any other languages are spoken please specify: ________________________________________________ Is this location Handicap Accessible? Yes No Does your Facility Offer Complimentary transportation for patients: Yes No Location Hours Patients Are Seen (please include evenings and weekends if applicable): Sunday Monday Tuesday Wednesday Thursday Friday Saturday

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pages 7-10 for

EACH LICENSED

PT / OT / DC / LAC / SLP

PRACTITIONER.

Make additional copies as needed. Applications submitted without fully

completing pages 7-10 for each PT/OT/DC/LAC/SLP practitioner will be declined.

Page 10 must be signed by the practitioner and may NOT be signed on his/her

behalf by another party or representative.

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Individual Practitioner Information – Pages 7-10 PLEASE INCLUDE INFORMATION FOR ALL THERAPISTS, DCs and/or LACs AT ALL LOCATIONS. Each Practitioner will need to complete the following: Practitioner Information (p.7), Work History (p.8) Disclosure Questions (p.9), Standard Authorization & Release (p.10) portions of the application. Standard Release must be signed by the individual practitioner.

Practitioner Name: ________________________________________________________________________ Maiden Name (if applicable):________________________ Other Name (if applicable):_________________________

Date of Birth (MM/DD/YYYY):_________________ Professional Degree: ______________________ Issuing Institution: _______________________________ Address of Issuing Institution: _______________________________________________________________ Degree: ____________________ Attendance Dates (MM/DD/YYYY to MM/DD/YYYY) ___________________________

Post-Graduate Education: Internship Residency Fellowship Teaching Appointment

Specialty: _______________________________ Institution: ____________________________________ Address of Institution: ____________________________________________________________________ Program Completed: Yes No Attendance Dates (MM/DD/YYYY to MM/DD/YYYY) ________________________

Program Director: __________________ Current Program Director (if known) _________________________

License Type: _________________ License Number: _____________ State of Registration: _____________ Original Date of Issue (MM/DD/YYYY) _________________ Expiration Date (MM/DD/YYYY) ____________________ Specialty: _______________________ National Board Certification: Yes No (if yes please indicate below)

CCS OCS PCS ECS GCS SCS WCS NCS CHT

Board Certification Date (MM/DD/YYYY) _________________ Recertification Date (MM/DD/YYYY) _______________ National Provider Identifier Number – NPI # (when available): _________________________________________ Are you a participating Medicare Provider? Yes No Medicare Provider Number: __________________ Are you a participating Medicaid Provider? Yes No Medicaid Provider Number: _________________ Workers Comp Experience: ________________________________________________________________

Do you have individual Professional Liability Insurance Coverage (Malpractice)? Yes No

If yes please provide a copy with your Credentialing Application

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Professional Work History - Please provide practice history, including month and year, for the past FIVE (5)

years. An explanation is required for any gap of six (6) months or longer that appear in your Professional Work History. If

you completed your professional education and training within the past five (5) years, the work history must cover the time

since then. Please make copies if additional space is needed.

Practitioner Name: ________________________________________________________________________

Current Institution/Facility Name: _____________________________________________________________

Address: ________________________________________________________________________________

Dates of Affiliation: From (MM/DD/YY):____________________ To: (MM/DD/YY):_______________________

Title: _________________________________________

Previous Institution/Facility Name: ____________________________________________________________

Address: ________________________________________________________________________________


Title: _________________________________________

Previous Institution/Facility Name: ____________________________________________________________

Address: ________________________________________________________________________________


Title: _________________________________________

Gaps in work history greater than six (6) months? Yes No If yes, please describe.

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

PLEASE ALSO ATTACH A COPY OF YOUR CURRENT CURRICULUM VITAE

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Disclosure Questions

Practitioner Name: ________________________________________________________________________ Medicare, Medicaid or other Governmental Program Participation:

1. Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs? Yes No

Other Sanctions or Investigations:

2. Are you currently or have you ever been the subject of an investigation by any licensing authority, education or training program, Medicare or Medicaid program, or any other private, federal or state health program? Yes

No

3. Have you ever received sanctions from or been the subject of investigation by any regulatory agencies (e.g. CLIA, OSHA, etc.)? Yes No

4. Have you ever been convicted of, pled guilty to, or pled no contest to any felony that is reasonably related to your qualifications, competence, functions or duties as a medical professional? Yes No

5. Have you ever been convicted of, pled guilty to, or pled no contest to any felony including an act of violence, child

abuse or a sexual offense? Yes No Ability to Perform Job:

6. Are you currently engaged in the illegal use of drugs? (“Currently” means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on one’s ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of the application; rather, that it has occurred recently enough to indicate the individual is actively engaged in such conduct. It does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law but does include the unlawful use of prescription controlled substances.) Yes No

7. Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety? Yes No

8. Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients? Yes No

9. Are you able to perform the essential functions of a practitioner in your area of practice, with or without reasonable accommodation? Yes No

Please use this Space to explain yes answers to any question except question #9. Include extra page(s) if additional space is needed.

_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

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Standard Authorization and Release: (Not for Use for Employment Purposes)

I understand and agree that, as part of the credentialing application process for participation with Align Networks (Entity) and any of the Entity’s affiliated entities, I am required to provide sufficient and accurate information for a proper evaluation of my current licensure, relevant training and/or experience, clinical competence, health status, character, ethics, and any other criteria used by the Entity for determining initial and ongoing eligibility for Participation. Each Entity and its representatives, employees and agent(s) acknowledge that the information obtained relating to the application process will be held confidential to the extent permitted by law.

I acknowledge and understand that my cooperation in obtaining information and my consent to the release of information do not guarantee that the Entity will contract with me as a provider of services. I understand that my application for Participation with the Entity is not an application for employment with the Entity and will not result in my employment by the Entity.

In this Authorization and Release, all references to the Entity, its Agent(s), and/or third party include their respective employees, directors, officers, advisors, counsel, and agents. The Entity or any of its affiliates or agents retains the right to allow access to the application information for purposes of a credentialing audit to customers and/or their auditors to the extent required in connection with an audit of the credentialing process and provided that the customer and/or their auditor executes an appropriate confidentiality agreement. I understand and agree that this Authorization and Release is irrevocable for any period during which I am an applicant for Participation at an Entity, a member of an Entity’s medical or health care staff, or a participating provider of an Entity. I agree to execute another form of consent if law or regulation limits the application of this irrevocable authorization. I understand that my failure to promptly provide consent may be grounds for termination or discipline by the Entity. I agreement that information obtained in accordance with the provisions of this Authorization and Release is not and will not be a violation of my privacy.

I certify that all information provided by me in my application is true, correct, and complete to the best of my knowledge and belief, and that I will notify the Entity and/or its Agent(s) within 10 days of any material changes to the information I have provided in my application or authorized to be released pursuant to the credentialing process. I understand that corrections to the application are permitted at any time prior to a determination of Participation by the Entity, and must be submitted in writing, and must be dated and signed by me. I understand and agree that any material misstatement or omission in the application may constitute grounds for withdrawal of the application from consideration; denial or revocation of Participation; and/or immediate suspension or termination of Participation. This action may be disclosed to the Entity and/or its Agent(s). I attest by signing this application that the following statements are true:

I. This Facility(s) is licensed according to state law. II. Our Facility(s) has a current General Liability Insurance and vicarious liability insurance covering the facility and

each of the health care providers in our facilities.

I further acknowledge that I have read and understand the foregoing Authorization and Release. I understand and agree that a facsimile or photocopy of this Authorization and Release shall be as effective as the original.

________________________________________________

Practitioner Signature

________________________________________________ Practitioner Name (please print or type)

________________________________________________

Last 4 digits of Practitioner SSN or NPI (please print or type)

________________________________________________ (MM/DD/YYYY)

Please type or print in legible writing. Please ensure all information is provided and all copies of documents are

enclosed. Incomplete applications will not be processed and returned to you. Any questions please contact Your Align

Networks Enrollment Representative or email [email protected]

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Page 12 for

EACH PTA, COTA, ATC, LMT

Make additional copies as needed. Applications submitted without fully completing pages 12 for each PTA / COTA / ATC / LMT practitioner will be

declined.

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PTA, COTA, Massage Therapist, ATC(s) Professional/Specialty Information- PLEASE FILL OUT FOR ALL PTA, COTA, ATC, and LMT practitioners. Please make copies if necessary. Each individual will need to have completed Page 12 of the application.

Check Here if no PTA, COTA, ATC, or LMT practitioners are employed with your organization.

Name: __________________________________________________________________________________ Maiden Name (if applicable):________________________ Other Name (if applicable):_________________________

Date of Birth (MM/DD/YYYY):_________________ Professional Degree: ______________________ Issuing Institution: _______________________________ Address of Issuing Institution: _______________________________________________________________ Degree: ____________________ Attendance Dates (MM/DD/YYYY to MM/DD/YYYY) ___________________________

Post-Graduate Education: Internship Residency Fellowship Teaching Appointment

Specialty: _______________________________ Institution: ____________________________________ Address of Institution: ____________________________________________________________________ Program Completed: Yes No Attendance Dates (MM/DD/YYYY to MM/DD/YYYY) ________________________

Program Director: __________________ Current Program Director (if known) _________________________

License Type: _________________ License Number: _____________ State of Registration: _____________ Original Date of Issue (MM/DD/YYYY) _________________ Expiration Date (MM/DD/YYYY) ____________________ Specialty: _______________________ National Board Certification: Yes No (if yes please indicate below)

CCS OCS PCS ECS GCS SCS WCS NCS CHT

Board Certification Date (MM/DD/YYYY) _________________ Recertification Date (MM/DD/YYYY) _______________ National Provider Identifier Number – NPI # (when available): _________________________________________ Are you a participating Medicare Provider? Yes No Medicare Provider Number: __________________ Are you a participating Medicaid Provider? Yes No Medicaid Provider Number: _________________ Workers Comp Experience: ________________________________________________________________

Do you have individual Professional Liability Insurance Coverage (Malpractice)? Yes No If yes please provide a copy with your Credentialing Application

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Checklist of Credentialing Items - Completion Report Please verify the following items are completed/included with Application:

Facility: ITEMS Completed/Included Preferred Provider Agreement Signed and Dated in all Applicable Areas (If application is for Re-Credentialing Please Mark N/A) Yes No N/A Application Fully Completed Yes No Copy of Facility Insurance Face Sheet (General Liability Insurance) Yes No (Showing date of expiration and coverage amounts) Copy of Operating/Business License (Or Applicable Equivalent) Yes No N/A Copy of W-9 Form Yes No Copy of CMS Accreditation (required for all Medicare/Medicaid providers) Yes No N/A Copy of CARF Accreditation (if applicable) Yes No N/A

Individual Practitioners: ITEMS Completed/Included Application Fully Completed Yes No Authorization and Release Signed by each PT/OT/DC/LAC/SLP Practitioner Yes No Copy of Current State License for all Practitioners Yes No N/A Copy of National Board Certification or Recertification certificate(s) Yes No N/A Copy of Current Individual Malpractice Insurance Policy Face Sheet Yes No N/A (Showing date of expiration and coverage amounts) Current Curriculum Vitae for each PT/OT/DC/LAC/SLP Practitioner Yes No

provider credentialing application - align networks · (10/24/14) page 1 of 13 provider...

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