First
License
DEA
Number:_______________
Number:__________________
Exp.
Date:_________________
(mm/dd/yy)
Social Security Number:
Exp. Date:_________________
(mm/dd/yy)
MI
YES:
Number:______________
YES:
Expiration Number:______________
Number:______________
Expiration Number:______________
NO
NO
Medicare #:
Individual NPI:
Number:_______________Exp. Date:_________________
(mm/dd/yy)
If YES please provide
Email Address
__________________________________________
Name_____________________
NPI _____________________
N/A
YES
NO
________________________________
Specialty: (Please indicate in this area the specialty obtained with State Board or Professional Board)
Name and Title of Contact Person for Credentialing (if other than
provider)
YES
NO
City:
State:
Telephone:
Fax:
Zip Code:
1C1 (List the city/town, State, and Zip code for all locations where health care services are rendered in patients homes)
City/Town
Zip
City/Town
Zip
City/Town
1.
2.
3.
4.
5.
6.
Page 1 of 16
Zip
City:
State:
Telephone:
Fax:
Contact Person
Phone Number
Zip Code:
Telephone Number:
Office Hours
AM Hours
Former Patients
City/Town:
State:
Fax Number:
Monday
Zip Code
Email Address:
Tuesday
Friday
Saturday
PM Hours
SECTION 1D. ADDITIONAL OFFICES, COMPLETE THE FOLLOWING AREA (OFFICE 2) (For additional offices, make copies of this
City:
State:
Telephone:
Fax:
Contact Person
Phone Number
Zip Code:
City/Town:
Telephone Number:
Fax Number:
Former Patients
State:
Zip Code:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
PM Hours
Page 2 of 16
Name
(Father's last name, Mother's last name, First Name,
MI)
Professional
License Exp. Date
(if applicable)
Professional License #
(if applicable)
Title
SECTION 1F. - IMAGES PRODUCTION INFORMATION FOR RADIOLOGY, ONCOLOGY OR HEMATOLOGY ONLY
Is your contracting specialty Radiology, Oncology or Hematology or will you bill for any images production services?
Yes
No
N/A
If you answered No or N/A to the question above please proceed to next Section below, if you answered, Yes, continue below.
Do you have any medical equipment that you use as part of your practice?
Yes
Do you own a medical facility where you render imaging services such as, but not limited to, a radiology facility or dialysis center? Please refer to Facility
Application.
Do you have any medical equipment such as x-ray or diagnostic equipment, which you use as part of your medical practice?
provide a list of such equipment. (Attachment III)
Yes
No. If Yes,
________________________
_________________________
Are you a foreign medical school graduate and have an ECFMG Certificate?
Yes
No
Yes
Yes
No
No
No
Page 3 of 16
From (mm/yr.)
To Present
From (mm/yr.)
To (mm/yr.)
From (mm/yr.)
To (mm/yr.)
From (mm/yr.)
To (mm/yr.)
From (mm/yr.)
To (mm/yr.)
If you have any gaps in the last five years of your work history, please explain reason for gap:
Location
Hospital/Group Name
Location
Yes
Active
Pending
Active
Pending
Associate
Provisional
Associate
Provisional
Courtesy
Staff
Courtesy
Staff
Location
Hospital/Group/Clinic Name
Location
N/A
SECTION 1K. - MALPRACTICE CLAIMS HISTORY- DURING THE LAST TEN (10) YEARS
Have you been named as a defendant/co-defendant in any malpractice suit, including arbitration or any malpractice claim
settlement ever been paid by you or paid on your behalf?
Yes
No
Yes
No
Page 4 of 16
Yes
No
Do you have any ongoing physical or mental health impairment or condition, which would make you unable, with or without
accommodation, to perform the essential functions of a practitioner in your area of practice, or unable to perform those
essential functions without a direct threat to the health and safety of others?
Yes
No
Have you, the Applicant/Provider in Section I, under any current or former name or business identity, within ten
years from the date of this statement, ever:
A.
Had a final adverse action, conviction, exclusion, revocation or suspension by any state, including the Common Wealth
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
G. Ever been convicted of any crime (excluding traffic or parking violations) or pending any litigation for an alleged crime?
Yes
No
H.
Yes
No
Yes
No
Yes
No
Yes
No
of Puerto Rico or federal, state or local government program or agency (ex. Medicare, Medicaid, TITLE V or Title XX)?
B.
Been convicted of any felony or misdemeanor involving fraud or abuse in any federal, state or local government
program or agency (ex. Medicare, Medicaid, TITLE V or Title XX?
C.
Found liable of fraud or abuse involving any federal, state or local government program or agency (ex. Medicare,
Medicaid, TITLE V or Title XX) in any civil proceeding?
D.
Entered into a settlement in lieu of conviction for fraud or abuse involving any federal, state or local government program
or agency (ex. Medicare, Medicaid, TITLE V or Title XX)?
E.
Had your license, certificate or other approval to provide health care ever been excluded, revoked or suspended, from a
federal, state or local government program or agency (ex. Medicare, Medicaid, Title V or Title XX Program)?
F.
Ever lost or surrendered your license, certificate, or other approval to provide health care, while a disciplinary hearing
was pending?
Ever been convicted of a crime under the Criminal Control Act or are you currently under indictment for an alleged
crime?
I.
J.
Has your license, certificate, or other approval to provide health care, ever been disciplined by any licensing authority?
K.
Had your clinical privileges suspended, limited or terminated from any local or federal institution (hospital, health clinic,
other health facility, etc.)?
If you answered Yes to any question above, please complete Section 2B.1, then proceed to and all other
questions in section 2.
Section 2B.1:
Page 5 of 16
State
EFFECTIVE DATE(S) OF
Conviction, Exclusion, Revocation or
Suspension (Month/Day/Year)
/
/
/
Medicaid
Medicare
Other: Specify: _____________________
DATE(s) OF REINSTATEMENT(s)
(If Any)
(Month/Day/Year)
/
/
/
/
/
/
/
/
/
State
Medicaid
Medicare
Other: Specify: ______________________
EFFECTIVE DATE(S) OF
(Conviction, Exclusion, Revocation or
Suspension)
Month/Day/Year
/ /
/ /
/ /
DATE(s) OF REINSTATEMENT(s)
(If Any)
Month/Day/Year
/
/
/
/
/
/
State
Date Issued
(Month/Day/Year)
/ /
Agency
$
$
Page 6 of 16
City
/
State
/
Zip Code
NPI
Disclosing Entity
Address
City
NPI
State
Zip Code
TITLE
ADDRESS
YES
NO
DESCRIPTION
A.
B.
C.
D.
2. Has the provider had business transactions with any subcontractor totaling more than $25,000 during the preceding 12-month
period? If yes, give the information below for each subcontractor. (42 CFR 455.105). If response is NO, continue to question #3.
NAME
YES
NO
ADDRESS
A.
B.
C.
D.
2a. Provide the name and address of all persons with an ownership or control interest in each subcontractor named in question
#2. NOTE: Designate relationship to subcontractor listed above by using A., B., C., etc. (42 CFR 455.105)
NAME
N/A
ADDRESS
A.
B.
C.
D.
Page 7 of 16
YES
NO
NAME
ADDRESS
A.
B.
C.
D.
Questions 4 6 to be answered by fiscal agents and by all providers EXCEPT individual practitioners.
4. Provide the name and address of each person with an ownership or control interest in the provider/fiscal agent or in any subcontractor in which the
provider/fiscal agent has direct or indirect ownership of five percent or more. (42 CFR 455.104)
NAME
ADDRESS
A.
B.
C.
D.
5. Is any person named in question #4 related to another as spouse, parent, child, or sibling? If yes, give the name(s) of person(s)
and relationship(s). NOTE: Designate relationship to each person listed in question #4 by using A., B., C., etc. (42 CFR 455.104)
YES
NO
NAME
RELATIONSHIP
A.
B.
C.
D.
6. Does any person named in question #4 have an ownership or control interest in any other Medicaid provider or in any entity that
does not participate in Medicaid but is required to disclose certain ownership and control information because of participation in
any of the programs established under Title V, XVIII, or XX of the Act? If yes, give the name(s) of and address(es) of the Medicaid
provider or entity. NOTE: Designate relationship to each person listed in question #4 by using A., B., C., etc. (42 CFR 455.104)
NAME
YES
NO
ADDRESS
A.
B.
C.
D.
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be prosecuted under
applicable federal or State laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result
in denial of a request to participate or, where the entity already participates, a termination of its agreement or contract with the State agency.
Page 8 of 16
Telephone Number
City
State
Zip Code
City
Telephone Number:
State
Fax Number:
Zip Code
Please identify if the individual(s), agency or other, that submits claims on your behalf (Check One):
Also submits for the additional address
Only for primary address
Both primary and additional address
Other Specify: ____________________________________
Page 9 of 16
Specialty:
Middle Initial:
Date of Birth:
TYPE OF PROVIDER:
Individual Practice
Group Practice
Corporation
First Name:
List Tax ID number:
(Corporation or Group)
IF INDIVIDUAL:
NPI of Individual: (Check one)
Payee Address:
Telephone number
Middle Initial
City
State
List S.S.Number:
(Individual)
ZIP Code
Fax number
__________________________________________
Provider Name (Please Print)
__________________________________________
Provider Signature
Page 10 of 16
___________________________
Date
I understand and agree that, as part of the credentialing application process for participation, membership and/or clinical privileges
(hereinafter, referred to as Participation) at or with each healthcare organization indicated on the List of Authorized Organizations that
accompanies this Application (hereinafter , each healthcare organization on the List of Authorized Organizations is individually referred
to as the Entity) and any of the Entitys 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 that each Entity has its own criteria for acceptance, and I may be accepted or rejected by each independently. I further
acknowledge and understand that my cooperation in obtaining information and my consent to the release of information does not
guarantee that any Entity will grant me clinical privileges or 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 that acceptance of my application by the Entity
will not result in my employment by the Entity.
Authorization of investigation concerning application for participation. I authorize the following individuals including, without
limitation, the Entity, its representatives, employees, and/or designated agents; the entitys affiliated entities and their representatives,
employees and/or designated agents; and the Entitys designated professional credentials verification organization (collectively referred
to as Agents), to investigate information, which includes both oral and written statements , records, and documents, concerning my
application for participation. I agree to allow the Entity and/or its agent(s) to inspect and copy all records and documents relating to such
an investigation.
Authorization of third-party sources to release information concerning application for participation. I authorize any third party,
including, but not limited to, individuals, agencies, medical groups responsible for credentials verification, corporations, companies,
employers, former employers, hospitals, health plans, health maintenance organizations, managed care organizations, law enforcement
or licensing agencies, insurance companies, educational and other institutions, military services, medical credentialing and accreditation
agencies, professional medical societies, the Federation of State Medical Boards, the National Practitioner Data Bank, Junta de
Licenciamiento y Disciplina Mdica de Puerto Rico, Office of Personnel Management (OPM), and the Office of the Inspector General
(OIG), to release to the Entity and/r its agent(s), information, including otherwise privileged or confidential information, concerning my
professional qualifications, credentials, clinical competence, quality assurance and utilization data, character, mental condition, physical
condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing
on my qualifications for participation in, or with, the Entity. I authorize my current and past professional liability carrier(s) to release my
history of claims that have been made and/or are currently pending against me. I specifically waive written notice from any entities and
individuals who provide information based upon this Authorization, Attestation and Release.
Authorization of release and exchange of disciplinary information. I hereby further authorize any third party at which I currently
have participation or had participation and/or each partys agents to release Disciplinary Information as defined below, to the Entity
and/or its agent(s). I hereby further authorize the agent(s) to release disciplinary information about any disciplinary action taken against
me to its participating entities at which I have participation, and as may be otherwise required by law. As used herein, Disciplinary
Action means information concerning (i) any action taken by such health care organizations, their administrators, or their medical or
other committees to revoke, deny, suspend, restrict, or condition my participation or impose a corrective action plan; (ii) any other
disciplinary action involving me, including, but not limited to, discipline in the employment context; or (iii) my resignation prior to the
conclusion of any disciplinary proceedings or prior to the commencement of formal charges, but after I have knowledge that such formal
charges were being (or are being) contemplated and/or were (or are) in preparation.
Release from liability. I release from all liability and hold harmless any Entity, its agent(s), and any other third party for their acts
performed in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of the Entity, its
agent(s), or other third party in connection with the gathering, release and exchange of, and reliance upon, information used in
accordance with this Authorization, Attestation and Release. I further agree not to sue any entity, any agent(s), or any other third party
for their acts, defamation or any other claims based on statements made in good faith and without malice or misconduct of such entity,
agent(s) or third party in connection with the credentialing process, This release shall be in addition to, and in no way shall limit, any
other applicable immunities provided by law for peer review and credentialing activities. In this Authorization, Attestation and Release, all
references to the entity, its agent(s) and/or other third party include their respective employees, directors, officers, advisors, counsel and
agents. The entity or any of its affiliates or agents retain 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 processes
and provided that the customer and/or their auditor executes an appropriate confidentiality agreement. I understand and agree that this
Authorization, Attestation and Release is irrevocable for any period during which I am an applicant for participation at an entity, a
Page 11 of 16
__________________________________________
Provider Name (Please Print)
___________________________________________
Provider Signature
Page 12 of 16
___________________________
Date
I agree to notify the Entity within thirty (30) working days, if any material changes occur affecting my professional status.
2.
I have read the contents of this application, and the information contained herein is true, correct, and complete. If I become
aware that any information in this application is not true, correct, or complete, I agree to notify the Entity of this fact within 30
days.
3.
I agree to ensure that the disclosing entity must(i) Keep copies of all these requests and the responses to them; (ii) Make
them available to the Health plan upon request; and (iii) Advise the Medicaid agency when there is no response to a request.
4.
I understand that any deliberate omission, misrepresentation, or falsification of any information contained in this application or
contained in any communication supplying information to the entity, any deliberate alteration of any text on this application form,
may be punished by criminal, civil, or administrative penalties including, but not limited to, the termination, denial or revocation
of billing privileges of any entity and/or the imposition of fines, civil damages, and/or imprisonment.
5.
I understand that Federal Financial Participation (FFP) is not available to a provider or fiscal agent that fails to disclose
ownership or control information as required by Medicare, Medicaid, Title V or Title XX Program.
6.
I understand that payment of a claim by Medicare, Medicaid, Title V or Title XX is conditioned upon the claim and the underlying
transaction complying with such laws, regulations, and program instructions (including, but not limited to, the Federal antikickback statute and the Stark law), and on the suppliers compliance with all applicable conditions of participation in Medicare,
Medicaid, Title V or Title XX program.
7.
I agree that any existing or future overpayment made to me (or to the organization listed in this application) by the Medicare,
Medicaid, Title V or Title XX program may be recouped through the withholding of future payments.
8.
I understand that the identification number issued to me can only be used by me or by a provider or supplier to whom I have
reassigned my benefits under current Medicare, Medicaid, Title V or Title XX Program regulations, when billing for services
rendered by me.
9.
I understand that I am responsible for the claims that are submitted on my behalf.
10. I certify that neither I, nor any managing employee listed on this application, is currently sanctioned, suspended, debarred, or
excluded by the Medicare or State Health Care Program, e.g., Medicare, Medicaid, Title V or Title XX program, or any other
Federal program, or is otherwise prohibited from providing services to program beneficiaries.
11. If N/A is answered in Billing Section, the supplier, applicant, provider is responsible for all claims submitted on his/her behalf.
CERTIFICATION STATEMENT
By signing the Certification Statement, I have read the contents of this application. My signature legally and financially binds this provider
to the laws, regulations, and program instructions of the Medicare, Medicaid, and Local, Title V and/or Title XX programs. By my
signature, I certify that the information contained herein is true, correct, and complete and I authorize the entities and its agent(s) to
verify this information. If I become aware that any information in this application is not true, correct, or complete, I agree to notify this fact
immediately.
_____________________________________________
Provider Name (Please Print)
______________________________________________
Provider Signature
Page 13 of 16
___________________________
Date
Page 14 of 16
Page 15 of 16
TYPE
MODEL
BRAND
YEAR
Conventional Radiology
Interventional Radiology
Ultrasound
Conventional Sonography
Vascular Sonography
CT
PET
PET/CT
MD CT (Multi detector)
MRI
MRA
Mammography
Sonomammography
Nuclear Medicine
Bone Densitometry
Stereotactic Biopsy
(ultrasonic, aspiration by
needle)
Fluoroscopy
Other
Page 16 of 16