HMSA BEHAVIORAL HEALTH FACILITY/PROGRAM CREDENTIALING DOCUMENT CHECKLIST

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "HMSA BEHAVIORAL HEALTH FACILITY/PROGRAM CREDENTIALING DOCUMENT CHECKLIST"

Transcription

1 HMSA BEHAVIORAL HEALTH FACILITY/PROGRAM CREDENTIALING DOCUMENT CHECKLIST Enclosed you will find: A. HMSA Facility/Program Application form Please complete the application and include the requested documentation. For each item below please separate with the corresponding numbered tab (1 15): 1. Completed Application Form 2. A copy of your current Professional Liability Insurance Policy which shows limits of liability and expiration dates. All clinical staff with patient contact must be covered by organization policy or have individual coverage. 3. A copy of ALL Current State licenses/certifications for the program or facility. 4. A copy of your Current Joint Commission Accreditation (JCAHO), Rehabilitation Accreditation Commission Certificate (CARF), Certificate of Accreditation (COA), Alcohol and Drug Abuse Division (ADAD) Accreditation or other national accreditation certificates. 5. Staff roster and staff resumes with copies of appropriate licensure and or certification (only clinical staff who have patient contact). Include name and resume of physician designated as the Clinical Program Director/Medical Director. If clinical staff are non-participating HMSA practitioners (MD, PHD, APRN, CSW), please provide policy for credentialing. 6. Organizational chart and staff roster showing positions 7. Board of Directors roster 8. Copy of patient handbook and handbook for significant other, if applicable 9. Patient record sample 10. Patient Bill of Rights. 11. Program Description 12. Treatment protocols 13. Policy for supervision of non- licensed clinical staff 14. Please provide a summary of your procedure for involuntary admission 15. Attach copies of your QI/UM Policy and Procedure MH_Facility_Initial Application_

2 HMSA BEHAVIORAL HEALTH FACILITY/PROGRAM APPLICATION FORM Facility/Program/Program Legal Name: Business Name: TAX ID #: Mailing Address: Location Address: County: Main Phone # : Main Fax #: (Attach additional sheet if more locations) If Applicable (Please attach copy) : Medicare #: Medicaid #: Setting: Category: isorders Clinical Service / Management: Name: Phone#: Fax #: Administrative Contact: Name: Phone #: Fax: MH_Facility_Initial Application_

3 Corporate Owner: Name: Corporate Address: Please list the key contacts at your Facility/Program: (If different from page 1) Contact for Admissions Corporate Office Contact Name: Phone#: Name: Phone#: Medical Director (psychiatric) Name: Phone#: Medical Director (substance abuse) Name: Phone#: Business Office (billing) Name: Phone#: 1. List your geographic service area: 2. How is the Facility/Program/Program licensed? (check all that apply) ter 3. Is your Facility/Program accessible to the handicapped? 4. Chemical Dependency services are based on: -specify: 5. Does your Facility/Program have a university association? If yes, with which university: 6. Does the Facility/Program have a research component? MH_Facility_Initial Application_

4 7. Emergency Room Services a. If no emergency room services, which acute care Facility/Program(s) provide emergency room services? Is your relationship with them contractual? b. Specify hours: c. Emergency substance abuse services evaluation services in ER? Specify hours: d. Other, please specify: 8. Facility/Program License and Accreditation Information. Please list and attach current copies of each that apply: a. State License: Number: Exp. Date: b. Is Facility/Program Accredited: If YES Name of accrediting organization Attach copy of current certificate If NO Are there plans to be accredited? If YES, Date of expected accreditation By whom If NO, please explain below. c. Below, please list any other licenses or certifications that the Facility/Program has acquired. Include current copies of each. If you need more space, please use a separate sheet of paper. License Name: Number: Exp. Date: License Name: Number: Exp. Date: MH_Facility_Initial Application_

5 9. Facility/Program Evaluation: a. Does the Facility/Program conduct regular quality assurance reviews? b. b. Does the Facility/Program conduct regular quality reviews for utilization management? If yes, how often do they occur? Quality/effectiveness: Utilization Management: c. Please send a written sample of your guidelines for measuring quality/effectiveness and utilization management. (Preferably, copies of policy/procedure manuals, reports and any lists of the standards that the Facility/Program is measured against). d. If was checked, specify the criteria that is used to evaluate Facility/Program quality/effectiveness. 10. Liability Information:(Please include a current copy of malpractice face sheet with this application). The limits of liability can not be lower than 1 Million/1 Million. a. Carrier Name: b. Policy Number: c. Coverage Limits: d. Expiration Date: 11. Malpractice Claim History: 1. Has the Facility/Program or any shareholders/owners/partners ever been named in any malpractice action? 2. Has the Facility/Program or any shareholders/owners/partners ever had or currently have pending any legal action? 3. Has the Facility/Program or any shareholders/owners/partners ever had professional liability insurance refused, declined, canceled or accepted on special terms? 4. Has any government agency ever investigated, suspended, revoked, or taken action against your license to conduct business? 5. At any time, has any license or certification been revoked, reduced, denied, or suspended by others or voluntarily given up by the program, or are any actions which may lead to such conclusions under way? MH_Facility_Initial Application_

6 6. At any time, have any memberships in professional organizations ever been revoked, reduced, denied, or suspended by others or voluntarily given up by the program, or are any actions which may lead to such conclusions under way? 7. Has the Facility/Program or any shareholders/owners/partners ever been convicted of a crime, excluding misdemeanors? 8. Has the Facility/Program ever been assessed a penalty, conviction or suspension or is the Facility/Program currently under investigation by a Medicaid or Medicare program? 9. Number of Claims (check one) (more) 10. Has your facility / program ever been excluded from any Federal health programs? MH_Facility_Initial Application_

7 FACILITY/PROGRAM S STATEMENT We certify that all of the above information is true, complete and correct to the best of our knowledge and belief and is made in good faith. We further understand that any false or incomplete information knowingly provided by us may be ground for our dismissal. We hereby authorize HMSA or its designees, to verify and release any and all of the information contained herein as may be necessary to evaluate our application to become a provider with HMSA. Print Name Title Authorizing Signature Date MH_Facility_Initial Application_

CareLink Network Provider Application

CareLink Network Provider Application COMPLETION OF THIS APPLICATION DOES NOT GUARANTEE A CONTRACT WITH CARELINK NETWORK Instructions: Please complete one application for each organization and include unique service information for each site

More information

ONE CALL MEDICAL INC. NEURODIAGNOSTIC PHYSICIAN APPLICATION

ONE CALL MEDICAL INC. NEURODIAGNOSTIC PHYSICIAN APPLICATION ONE CALL MEDICAL INC. NEURODIAGNOSTIC PHYSICIAN APPLICATION Provider has the right to review information submitted to support credentialing, correct erroneous information, to be informed of application

More information

PRACTITIONER CREDENTIALING APPLICATION Advanced Practice Nurse Prescriber, Certified Nurse Midwife, Physician Assistant

PRACTITIONER CREDENTIALING APPLICATION Advanced Practice Nurse Prescriber, Certified Nurse Midwife, Physician Assistant PRACTITIONER CREDENTIALING APPLICATION Advanced Practice Nurse Prescriber, Certified Nurse Midwife, Physician Assistant Prior to submitting this application it is required that you contact the Provider

More information

ARKANSAS BOARD OF PODIATRIC MEDICINE

ARKANSAS BOARD OF PODIATRIC MEDICINE ARKANSAS BOARD OF PODIATRIC MEDICINE APPLICATION FOR LICENSE TO PRACTICE PODIATRIC MEDICINE 1. Name: Social Security Number: (As to appear on License) 2. Address: 3. Address you wish License to be mailed:

More information

Cenpatico Facility/Agency Credentialing Application INSTRUCTIONS

Cenpatico Facility/Agency Credentialing Application INSTRUCTIONS Cenpatico Facility/Agency Credentialing Application INSTRUCTIONS Please complete the application thoroughly in its entirety. The checklist below may not be exhaustive of all materials, but is provided

More information

1. Legal Name of the Primary Applicant: 3. Corporate Contact Name: 4. Corporate Contact Phone:

1. Legal Name of the Primary Applicant: 3. Corporate Contact Name: 4. Corporate Contact Phone: PSIC RPG Association Large Group Dental Application A. APPLICANT Information 1. Legal Name of the Primary Applicant: 2. of Incorporation or Formation: MO/DAY/YR 3. Corporate Contact Name: 4. Corporate

More information

Los Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children

Los Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children Los Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children This application is exclusively for prescribing practitioners

More information

North Carolina Department of Insurance. Uniform Application. To Participate as a Health Care Practitioner

North Carolina Department of Insurance. Uniform Application. To Participate as a Health Care Practitioner orth Carolina Department of Insurance Uniform Application To Participate as a Health Care Practitioner ote: Please send completed applications directly to the organizations with which you seek to contract.

More information

Organization Profile and Credentialing Application

Organization Profile and Credentialing Application Organization Profile and Credentialing Application Initial Profile and Application Re-credentialing Application and Profile Review Mark all areas of the application NA for any item not applicable I. Certification,

More information

New Jersey Physician Recredentialing Application (Please type or print)

New Jersey Physician Recredentialing Application (Please type or print) New Jersey Physician Recredentialing Application (Please type or print) All sections must be completed fully or clearly marked as not applicable. No area should be left blank. SECTION 1 Personal Information

More information

PERSPECTIVES NATIONAL PROVIDER/AFFILIATE APPLICATION

PERSPECTIVES NATIONAL PROVIDER/AFFILIATE APPLICATION DIVISION OF CLINICAL OPERATIONS PERSPECTIVES EAP Updated 01/10 PERSPECTIVES NATIONAL PROVIDER/AFFILIATE APPLICATION Please PRINT or TYPE all information so it is legible. Use only blue or black ink. Do

More information

CREDENTIALING PROFILE

CREDENTIALING PROFILE CREDENTIALING PROFILE Please type or print all of the information requested on this Profile. Incomplete profiles cannot be accepted and will be returned for completion. Faxed and photocopies of this form

More information

Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA)

Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA) Updated 1/1/2013 Specialty Surgery Center Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA) Dear Anesthesia Provider, Thank you for your interest in providing services at

More information

Rehab Net of Arkansas. Provider Application

Rehab Net of Arkansas. Provider Application Rehab Net of Arkansas Provider Application Discipline P.T. O.T. S.L.P. (1) Business Name Physical Address FACILITY DATA Phone Fax (2) Billing Address Phone Fax (3) Mailing Address (4) Owner/Contact Person

More information

APPLICATION FOR ALLIED PROFESSIONAL STAFF

APPLICATION FOR ALLIED PROFESSIONAL STAFF Office of Medical Affairs 736 Irving Ave Syracuse NY 13210 Phone: 315-470-7646 APPLICATION FOR ALLIED PROFESSIONAL STAFF Circle appropriate category CRNA Medical Physicist Research Assistant CST/Dntal

More information

To Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan

To Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan To Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan 1. Complete the SC Uniform Managed Care Provider Credentialing Application. 2. Enclose copies of the following items: A. State

More information

A. Clearly print or type information in each block. Complete each section entirely, indicate NOT APPLICABLE (N/A) where necessary.

A. Clearly print or type information in each block. Complete each section entirely, indicate NOT APPLICABLE (N/A) where necessary. Provider Application For use by Physicians and Independent Health Care Professionals BCBSF Provider Number: HCFA UPIN #: NPI #: PURPOSE: This Provider Application will be used for assigning a provider

More information

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY APPLICATION FOR TEACHING PERMIT Chapter 466.002, Florida Statutes Rule 64B5-7.005, Florida Administrative Code Applications will be accepted only if completed

More information

North Carolina Delta Dental s Recredentialing Application

North Carolina Delta Dental s Recredentialing Application Delta Dental of North Carolina North Carolina Delta Dental s Recredentialing Application INCOMPLETE APPLICATIONS WILL BE RETURNED, WHICH WILL DELAY THE RECREDENTIALING PROCESS 1. The attached Recredentialing

More information

REQUIREMENTS FOR LICENSURE:

REQUIREMENTS FOR LICENSURE: Email: st-medicine@pa.gov INITIAL APPLICATION FOR A NURSE-MIDWIFE LICENSE 1. This license class does not include prescriptive authority. If you wish to hold a certificate for prescriptive authority, you

More information

State of Utah Department of Commerce Division of Occupational and Professional Licensing

State of Utah Department of Commerce Division of Occupational and Professional Licensing State of Utah Department of Commerce Division of Occupational and Professional Licensing Official Use Only Number: Date Approved/Denied: Approved/Denied By: Psychologist APPLICANT INFORMATION Full Legal

More information

1. Name of applicant Last First Middle. Home Phone FAX number E-mail address. Complete title of your medical professional designation

1. Name of applicant Last First Middle. Home Phone FAX number E-mail address. Complete title of your medical professional designation 2 Park Avenue 8 British American Blvd. New York, NY 10016 Latham, NY 12110 Tel: 212-576-9800 Tel: 518-786-2700 2 Clinton Square 90 Merrick Avenue Syracuse, NY 13202 East Meadow, NY 11554 Tel: 315-428-1188

More information

1. Name of applicant Last First Middle. Complete title of your medical professional designation. 12:01 AM E.S.T. on Month Day Year

1. Name of applicant Last First Middle. Complete title of your medical professional designation. 12:01 AM E.S.T. on Month Day Year 2 Park Avenue 8 British American Blvd. New York, NY 10016 Latham, NY 12110 Tel: 212-576-9800 Tel: 518-786-2700 2 Clinton Square 90 Merrick Avenue Syracuse, NY 13202 East Meadow, NY 11554 Tel:315-428-1188

More information

State of Utah Department of Commerce Division of Occupational and Professional Licensing

State of Utah Department of Commerce Division of Occupational and Professional Licensing State of Utah Department of Commerce Official Use Only Number: Date Approved/Denied: Approved/Denied By: Certified Nurse Midwife APPLICANT INFORMATION Full Legal Name: First Middle Last All Previous Legal

More information

PHYSICIAN APPLICATION FOR EMPLOYMENT

PHYSICIAN APPLICATION FOR EMPLOYMENT PLEASE COMPLETE The Following. DATE Name Last First Middle Maiden Address City State Zip Date of Birth Place of Birth Social Security Number US Citizen Home Phone Email Address Specialty/Sub-specialty

More information

CRNA APPLICATION/CHECKLIST INSTRUCTIONS:

CRNA APPLICATION/CHECKLIST INSTRUCTIONS: MAXIM is an equal opportunity Employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin,

More information

NURSE PRACTITIONER/PHYSICIANS ASSISTANT APPLICATION GENERAL INFORMATION. Last Name First Middle. Place of Birth Social Security #

NURSE PRACTITIONER/PHYSICIANS ASSISTANT APPLICATION GENERAL INFORMATION. Last Name First Middle. Place of Birth Social Security # Page 1 NURSE PRACTITIONER/PHYSICIANS ASSISTANT APPLICATION GENERAL INFORMATION Last Name First Middle Place of Birth Social Security # Home Address City State Zip Office Address City State Zip DOB Emergency

More information

Nurse Practitioner Application for Professional Liability Insurance Additional Insured Basis*

Nurse Practitioner Application for Professional Liability Insurance Additional Insured Basis* Nurse Practitioner Application for Professional Liability Insurance Additional Insured Basis* IMPORTANT INSTRUCTIONS PLEASE READ CAREFULLY *Coverage on an Additional Insured Basis provides coverage only

More information

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY NON-PROFIT CORPORATION PERMIT APPLICATION

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY NON-PROFIT CORPORATION PERMIT APPLICATION FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY N-PROFIT CORPORATION PERMIT APPLICATION Applications will be accepted only if completed by an officer of the non-profit organization. Any questions not applicable

More information

Comprehensive Psychiatric Emergency Program of MHMRA of Harris County Co-occurring Disorders Unit PROVIDER APPLICATION

Comprehensive Psychiatric Emergency Program of MHMRA of Harris County Co-occurring Disorders Unit PROVIDER APPLICATION Co-Occurring Disorders Residential Treatment Program Facility Checklist Complete, date and sign the enclosed Facility Application. Complete, date and sign the W-9 Form for each TIN. Attach a current copy

More information

REQUIREMENTS FOR CERTIFICATION:

REQUIREMENTS FOR CERTIFICATION: Email: st-medicine@pa.gov INITIAL APPLICATION FOR NURSE-MIDWIFE PRESCRIPTIVE AUTHORITY * A separate prescriptive authority collaborative agreement must be submitted for each physician, physician group

More information

STATE OF FLORIDA BOARD OF ACUPUNCTURE APPLICATION FOR LICENSURE WITH INSTRUCTIONS

STATE OF FLORIDA BOARD OF ACUPUNCTURE APPLICATION FOR LICENSURE WITH INSTRUCTIONS STATE OF FLORIDA BOARD OF ACUPUNCTURE APPLICATION FOR LICENSURE WITH INSTRUCTIONS Board of Acupuncture 4052 Bald Cypress Way, Bin # C-06 Tallahassee, FL 32399-3256 (850) 488-0595 September 2012 Edition

More information

HENDRICK MEDICAL CENTER INITIAL APPOINTMENT ADDENDUM

HENDRICK MEDICAL CENTER INITIAL APPOINTMENT ADDENDUM Attachment H HENDRICK MEDICAL CENTER INITIAL APPOINTMENT ADDENDUM TO THE TEXAS DEPARTMENT OF INSURANCE (TDI) STANDARDIZED CREDENTIALING APPLICATION SECTION ONE - PERSONAL INFORMATION Last Name: First Name:

More information

Home and Community Based Services (HCBS) Provider Credentialing/Re-Credentialing Application

Home and Community Based Services (HCBS) Provider Credentialing/Re-Credentialing Application Home and Community Based Services (HCBS) Provider Credentialing/Re-Credentialing Application GENERAL INFORMATION Corporate (as assigned on W-9) Doing Business As (if applicable) Individual Provider (if

More information

VANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION

VANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION VANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION GENERAL INFORMATION Primary Practice Facility Location The type of application being submitted: Initial Credentialing Re-Credentialing Hospital (Acute,

More information

Independent Contractor Information CRNA

Independent Contractor Information CRNA Dear Provider: Thank you for your interest in Locum Leaders, your premier locum tenens agency. Locum Leaders provides A++ rated occurrence malpractice insurance through Med Pro. Please complete this entire

More information

Surgical Center of Greensboro/Orthopaedic Surgical Center Div of Surgical Care Affiliates

Surgical Center of Greensboro/Orthopaedic Surgical Center Div of Surgical Care Affiliates Allied Health Staff Application Instructions We are pleased to provide you with our Allied Health Staff application packet. Please do not write see attached or see resume or CV on the application. All

More information

INSTRUCTIONS. Please see Board Rules Chapter 14: RULES FOR USE OF SEDATION AND GENERAL ANESTHESIA BY DENTISTS for further explanation.

INSTRUCTIONS. Please see Board Rules Chapter 14: RULES FOR USE OF SEDATION AND GENERAL ANESTHESIA BY DENTISTS for further explanation. INSTRUCTIONS To Moderate Sedation Applicant: Enclosed please find an application from the Maine Board of Dental Examiners regarding the administration of moderate sedation. No dentist shall be required

More information

(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE:

(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE: APPLICATION FOR PARAMEDICS, EMT S, NURSE ANESTHETISTS, NURSE PRACTITIONERS AND PHYSICIANS AND SURGEONS ASSISTANTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis) 1. APPLICANT INFORMATION APPLICANT

More information

NEIGHBORHOOD HEALTH PLAN OFRHODE ISLAND CREDENTIALING PRACTITIONER APPLICATION

NEIGHBORHOOD HEALTH PLAN OFRHODE ISLAND CREDENTIALING PRACTITIONER APPLICATION NEIGHBORHOOD HEALTH PLAN OFRHODE ISLAND CREDENTIALING PRACTITIONER APPLICATION Neighborhood accepts the Council for Affordable Quality Healthcare (CAQH) application in lieu of Neighborhood s standard credentialing

More information

EMPLOYMENT/CREDENTIALING APPLICATION

EMPLOYMENT/CREDENTIALING APPLICATION Beacon Specialized Living Services, Inc. EMPLOYMENT/CREDENTIALING APPLICATION We do not discriminate on the basis of race, color, religion, national origin, sex, age or disability. It is our intention

More information

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY DENTAL RADIOGRAPHY CERTIFICATION APPLICATION Chapter 466.004 and 466.017(5), Florida Statutes Rule 64B5-9.011, Florida Administrative Code SPECIAL TES AND INSTRUCTIONS: 1. A N-REFUNDABLE fee of $35.00

More information

LOCUM TENENS APPLICATION Page 1 of 4

LOCUM TENENS APPLICATION Page 1 of 4 Page 1 of 4 This form is only valid for Locum Tenens providing coverage for up to 60 days. SECTION I PROVIDER INFORMATION This section to be completed by the PacificSource participating practitioner. Please

More information

PLEASE ALLOW AT LEAST 60 DAYS FOR PROCESSING INSTRUCTIONS FOR APPLICANTS WHO HOLD NCCPA CERTIFICATION

PLEASE ALLOW AT LEAST 60 DAYS FOR PROCESSING INSTRUCTIONS FOR APPLICANTS WHO HOLD NCCPA CERTIFICATION Regular Mailing Address P.O. BOX 2649 HARRISBURG, PA 17105-2649 Email: st-medicine@pa.gov Courier Delivery Address 2601 NORTH THIRD STREET HARRISBURG, PA 17110 717-783-1400/717-787-2381 APPLICATION FOR

More information

State of Utah Department of Commerce Division of Occupational and Professional Licensing

State of Utah Department of Commerce Division of Occupational and Professional Licensing State of Utah Department of Commerce Division of Occupational and Professional Licensing Official Use Only Number: Date Approved/Denied: Approved/Denied By: Clinical Mental Health Counselor APPLICANT INFORMATION

More information

FLORIDA BLUE HOSPITAL, ANCILLARY FACILITY AND SUPPLIER BUSINESS APPLICATION. Facility Name: Legal Name (if different from above):

FLORIDA BLUE HOSPITAL, ANCILLARY FACILITY AND SUPPLIER BUSINESS APPLICATION. Facility Name: Legal Name (if different from above): FLORIDA BLUE HOSPITAL, ANCILLARY FACILITY AND SUPPLIER BUSINESS APPLICATION Florida Blue Provider Number: Facility Name: Legal Name (if different from above): Facility Physical Address: City: State: Zip

More information

REHAB PROVIDER NETWORK Professional Staff Credentialing Form

REHAB PROVIDER NETWORK Professional Staff Credentialing Form REHAB PROVIDER NETWORK Professional Staff Credentialing Form ***** THERAPIST LICENSE MUST BE ATTACHED TO THIS FORM ***** The information requested on this form is required to certify your status as a licensed

More information

ALL APPLICANTS MUST COMPLETE THE FOLLOWING:

ALL APPLICANTS MUST COMPLETE THE FOLLOWING: APPLICATION FOR ATHLETIC TRAINER LICENSE (This application may also be used for a temporary license) 1. An applicant for licensure shall meet one of the following requirements: a. Be a graduate of an approved

More information

STATE OF CONNECTICUT

STATE OF CONNECTICUT STATE OF CONNECTICUT DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES A Healthcare Service Agency DANNEL P. MALLOY GOVERNOR PATRICIA A. REHMER, MSN COMMISSIONER CONNECTICUT DEPARTMENT OF MENTAL HEALTH

More information

PLEASE READ BEFORE COMPLETING APPLICATION

PLEASE READ BEFORE COMPLETING APPLICATION PLEASE READ BEFORE COMPLETING APPLICATION Information for Licensure: SOCIAL WORKER (LSW) Each item on the enclosed application must be completed. Allow 30 days for processing of the application. Failure

More information

M. Please itemize your historical visits (all) for the past five (5) years; and number of expected visits for this year.

M. Please itemize your historical visits (all) for the past five (5) years; and number of expected visits for this year. ED GROUP APPLICATION FOR CLAIMS-MADE PROFESSIONAL LIABILITY INSURANCE Please note you are applying for a claims-made policy form of professional liability insurance. The coverage of this policy is limited

More information

Provider Selection Criteria for PreferredOne Participating Home Health Care Agencies

Provider Selection Criteria for PreferredOne Participating Home Health Care Agencies Provider Selection Criteria for PreferredOne Participating Home Health Care Agencies General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne product

More information

State of Utah Department of Commerce Division of Occupational and Professional Licensing

State of Utah Department of Commerce Division of Occupational and Professional Licensing State of Utah Department of Commerce Division of Occupational and Professional Licensing Official Use Only Number: Date Approved/Denied: Approved/Denied By: Retired Volunteer Health Care Practitioner APPLICANT

More information

Legal Name of Applicant Website Tax ID Number

Legal Name of Applicant Website Tax ID Number 500 Virginia St. E. Ste 1200 Tel: 304.343.3000 Charleston, WV 25301 Toll-Free: 888.998.7642 P.O. Box 3697 Fax: 304.342.0985 Charleston, WV 25336-3697 www.wvmic.com Agency Address Producer Agent Information

More information

A. Practice/Personal Data

A. Practice/Personal Data American Substance Abuse Professionals, Inc. 711 WEST 40TH STREET, SUITE 235 BALTIMORE, MARYLAND 21211 Phone: 888-792-2727 Fax 410-889-6234 go2asap.com SAP Affiliate Application A. Practice/Personal Data

More information

Please Note: Please send all documentation related to the credentialing portion of this documentation to:

Please Note: Please send all documentation related to the credentialing portion of this documentation to: Please ote: The application process is split into different actions. Please send all documentation related to the contracting portion of this documentation to: Fax to: (916)350-8860 Or email to: BSCproviderinfo@blueshieldca.com

More information

Allied Healthcare Professional (AHP) Professional Liability Application

Allied Healthcare Professional (AHP) Professional Liability Application Allied Healthcare Professional (AHP) Professional Liability Application Coverys RRG, Inc. Agency Name NOTICE: This policy is issued by your risk retention group. Your risk retention group may not be subject

More information

MOONLIGHTING INSTRUCTIONS:

MOONLIGHTING INSTRUCTIONS: MOONLIGHTING INSTRUCTIONS: Please Complete and Send the Forms on the Following 6 Pages to the Medical Staff Office at Box URMFG 278911. 1) URMC Moonlighting (extra work shift) Request Form, p. 1 of 6 2)

More information

Dental Provider Application

Dental Provider Application Dental Provider Application DENTAL APPLICATION I am applying to participate in the following EmblemHealth dental network(s): Preferred Preferred Plus Please use the checklist below to ensure we have all

More information

ENCLOSED IS THE FORM NECESSARY FOR SUBSTITUTE PHYSICIAN (LOCUM TENENS) COVERAGE

ENCLOSED IS THE FORM NECESSARY FOR SUBSTITUTE PHYSICIAN (LOCUM TENENS) COVERAGE ENCLOSED IS THE FORM NECESSARY FOR SUBSTITUTE PHYSICIAN (LOCUM TENENS) COVERAGE You must be a licensed physician in Texas. Complete and sign the Application for Coverage. Complete the Claim/Suit Information

More information

CHECK THE CIRCUMSTANCE UNDER WHICH YOU ARE SEEKING A TEMPORARY LICENSE: REQUIRED DOCUMENTS

CHECK THE CIRCUMSTANCE UNDER WHICH YOU ARE SEEKING A TEMPORARY LICENSE: REQUIRED DOCUMENTS Regular Mailing Address P.O. BOX 2649 HARRISBURG, PA 17105-2649 717-783-1400/717-787-2381 Email: st-medicine@pa.gov Courier Delivery Address 2601 NORTH THIRD STREET HARRISBURG, PA 17110 APPLICATION FOR

More information

Dental Initial Credentialing Application

Dental Initial Credentialing Application Dental Initial Credentialing Application Practitioner and Practice Information Name(last) (First) (Middle) Degree Social Security Number Personal NPI Date of Birth Gender Practice Name Practice Taxpayer

More information

TRICARE MANAGEMENT ACTIVITY (TMA) APPLICATION FOR TRICARE MENTAL HEALTH FACILITY CERTIFICATION

TRICARE MANAGEMENT ACTIVITY (TMA) APPLICATION FOR TRICARE MENTAL HEALTH FACILITY CERTIFICATION TRICARE MANAGEMENT ACTIVITY (TMA) APPLICATION FOR TRICARE MENTAL HEALTH FACILITY CERTIFICATION FACILITY: Please check one appropriate facility/program: Psychiatric Partial Hospitalization Program (PHP)

More information

ORGANIZATIONAL ANCILLARY PROVIDER APPLICATION

ORGANIZATIONAL ANCILLARY PROVIDER APPLICATION ORGANIZATIONAL ANCILLARY PROVIDER APPLICATION Please complete each section thoroughly. Type or print clearly in black ink. Sign and date the application. YOU MUST INCLUDE THE FOLLOWING WITH THIS COMPLETED

More information

The University of Utah Health Plans offers the following plans and networks. Please specify the networks you are interested in participating with:

The University of Utah Health Plans offers the following plans and networks. Please specify the networks you are interested in participating with: Provider Networks Provider Applicant Process University of Utah Health Plans (UUHP) contracts with physicians and other health care professionals and facilities to offer provider networks essential to

More information

APPLICANTS MUST COMPLETE THE FOLLOWING:

APPLICANTS MUST COMPLETE THE FOLLOWING: Regular Mailing Address P.O. BOX 2649 HARRISBURG, PA 17105-2649 717-783-1400/717-787-2381 Email: st-medicine@pa.gov Courier Delivery Address 2601 NORTH THIRD STREET HARRISBURG, PA 17110 APPLICATION FOR

More information

Instructions For Clinical Nurse Specialist (CNS) Applicants

Instructions For Clinical Nurse Specialist (CNS) Applicants RETAIN FOR REFERENCE Instructions For Clinical Nurse Specialist (CNS) Applicants GENERAL INFORMATION: An applicant for Clinical Nurse Specialist certification must hold a current, unrestricted license

More information

(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE:

(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE: APPLICATION FOR PARAMEDICS, EMT S, NURSE PRACTITIONERS, AMBULANCE SERVICES AND PHYSICIANS AND SURGEONS ASSISTANTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis) APPLICANT S INSTRUCTIONS: 1. Answer

More information

PROFESSIONAL EMPLOYEE LIABILITY INSURANCE APPLICATION

PROFESSIONAL EMPLOYEE LIABILITY INSURANCE APPLICATION PROFESSIONAL EMPLOYEE LIABILITY INSURANCE APPLICATION All questions must be answered completely. If the answer to any question is NONE or NOT APPLICABLE, so state. Upon receiving a copy of your final application

More information

2. Be of good moral character. Have 2 recommendations completed on page 3.

2. Be of good moral character. Have 2 recommendations completed on page 3. STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA 17105-2649 717-783-1389 FAX 717-787-7769 Email st-socialwork@state.pa.us Website www.dos.pa.gov/social

More information

Physical Therapist Physical Therapist Assistant by Endorsement

Physical Therapist Physical Therapist Assistant by Endorsement State of Maine BOARD OF EXAMINERS IN PHYSICAL THERAPY Application information to assist in completing your application. This information is not designed to include all information on laws and rules and

More information

Physician Assistant Application for Professional Liability Insurance Additional Insured Basis*

Physician Assistant Application for Professional Liability Insurance Additional Insured Basis* Physician Assistant Application for Professional Liability Insurance Additional Insured Basis* IMPORTANT INSTRUCTIONS PLEASE READ CAREFULLY *Coverage on an Additional Insured Basis provides coverage only

More information

APPLICATION FOR LICENSURE INFORMATION SHEET / CHECKLIST (Check as Received) (Form KBLTCA-1)

APPLICATION FOR LICENSURE INFORMATION SHEET / CHECKLIST (Check as Received) (Form KBLTCA-1) KENTUCKY BOARD OF LICENSURE FOR LONG-TERM CARE ADMINISTRATORS P.O. Box 1360, Frankfort, Kentucky 40602 ~ 911 Leawood Drive, Frankfort, Kentucky 40601 (502)564-3296 Extension 226~ http://ltca.ky.gov TEMPORARY

More information

Provider Credentialing Application

Provider Credentialing Application 1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI 54449-8000 1.800.472.2363 or 715.221.9555 TTY: 1.877.727.2232 or 715.221.9898 Provider Credentialing Application Security Health Plan s Expectations

More information

Southwest Michigan Behavioral Health

Southwest Michigan Behavioral Health Southwest Michigan Behavioral Health Southwest Michigan Behavioral Health is an affiliation of Barry County Community Mental Health Authority, Kalamazoo Community Mental Health & Substance Abuse Services,

More information

(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE:

(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE: APPLICATION FOR PARAMEDICS, EMT S, NURSE ANESTHETISTS, NURSE PRACTITIONERS, AMBULANCE SERVICES AND PHYSICIANS AND SURGEONS ASSISTANTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis) 1. APPLICANT INFORMATION

More information

Application for Licensure as a Licensed Alcohol and Drug Counselor (LADC)

Application for Licensure as a Licensed Alcohol and Drug Counselor (LADC) State of Maine STATE BOARD OF ALCOHOL AND DRUG COUNSELORS Application information to assist in completing your application. This information is not designed to include all information on laws and rules

More information

Last Name First Middle

Last Name First Middle P.O. Box 327 Seattle, WA 98111-0327 DENTAL PROVIDER CREDENTIALING APPLICATION This application is not a contract. The information provided in this application is used to determine whether a practitioner

More information

Resident Credentialing Policy Wayne State University

Resident Credentialing Policy Wayne State University Resident Credentialing Policy Wayne State University REQUIREMENTS FOR INITIAL RESIDENT APPOINTMENT Residency Office Responsibilities: 1. Resident Initial Appointment Recommendation Letter: Initial applications

More information

I. PERSONAL INFORMATION. Degree and/or Title SS# Email. Birth Date Gender (Optional) Male Female Ethnicity (Optional)

I. PERSONAL INFORMATION. Degree and/or Title SS# Email. Birth Date Gender (Optional) Male Female Ethnicity (Optional) Pennsylvania Standard Application This form should be typed or legibly printed in black or blue ink. Please answer all questions completely and fully. If more space is needed than provided on this application,

More information

APPLICATION FOR NATIONAL EXAMINATION IN MARITAL & FAMILY THERAPY

APPLICATION FOR NATIONAL EXAMINATION IN MARITAL & FAMILY THERAPY Minnesota Board of Marriage and Family Therapy 2829 University Avenue SE, Suite 400 Minneapolis, MN 55414-3222 Telephone: (612) 617-2220 Fax: (612) 617-2221 Email: mft.board@state.mn.us Website: www.bmft.state.mn.us

More information

CREDENTIALING APPLICATION PACKET INSTRUCTIONS

CREDENTIALING APPLICATION PACKET INSTRUCTIONS CREDENTIALING APPLICATION PACKET INSTRUCTIONS 1) If you would like to register with CAQH, please see the CAQH brochure enclosed (entitled: Introducing Universal Credentialing Data Source ) for more information

More information

North Carolina Board of Dietetics/Nutrition License Categories

North Carolina Board of Dietetics/Nutrition License Categories North Carolina Board of Dietetics/Nutrition License Categories Category A: Applicant is currently registered with Commission on Dietetic Registration (CDR), OR applicant is provisionally licensed and is

More information

DRIVER CERTIFICATION OF SUBSTANCE ABUSE

DRIVER CERTIFICATION OF SUBSTANCE ABUSE DRIVER CERTIFICATION OF SUBSTANCE ABUSE NAME: S.S. # Part 40.25{j} requires Employers to ask Applicant/Driver whether he/she has tested positive or refused to test on any Pre-Employment alcohol or drug

More information

IOWA PLUMBING & MECHANICAL SYSTEMS BOARD

IOWA PLUMBING & MECHANICAL SYSTEMS BOARD IOWA PLUMBING & MECHANICAL SYSTEMS BOARD Contractor License Renewal Form Instructions Enclosed is an application for renewal of your Iowa Plumbing & Mechanical Systems Board contractor license. To expedite

More information

MARYLAND HOSPITAL CREDENTIALING APPLICATION

MARYLAND HOSPITAL CREDENTIALING APPLICATION Error! STATE OF MARYLAND DHMH MARYLAND HOSPITAL CREDENTIALING APPLICATION Please type or print. Incomplete or illegible applications will not be processed. I. PERSONAL INFORMATION Name (Last, First, Middle)

More information

Lincoln Memorial University- DeBusk College of Osteopathic Medicine Physician Assistant Program Supplemental Application

Lincoln Memorial University- DeBusk College of Osteopathic Medicine Physician Assistant Program Supplemental Application Lincoln Memorial University- DeBusk College of Osteopathic Medicine Physician Assistant Program Supplemental Application Date of Application: LMU ID # (if applicable): Name Last First Middle Preferred

More information

United Health Hire Credentialing Checklist. Dear Physician Assistant / Nurse Practitioner:

United Health Hire Credentialing Checklist. Dear Physician Assistant / Nurse Practitioner: Dear Physician Assistant / Nurse Practitioner: Thank you for your interest in United Health Hire. We are looking forward to working with you! We offer PA and NP Locum Tenens and Permanent Placement opportunities

More information

Dental Provider Practice Application

Dental Provider Practice Application and subsidiaries Dental Provider Practice Application How to Join the Avesis Network. Complete and sign the application Complete and sign the W-9 Complete and sign the Credential Verification Release Complete

More information

DEPARTMENT OF HEALTH. APPLICATION FOR LIMITED LICENSURE and Instructions

DEPARTMENT OF HEALTH. APPLICATION FOR LIMITED LICENSURE and Instructions DEPARTMENT OF HEALTH BOARD OF CLINICAL SOCIAL WORK, MARRIAGE AND FAMILY THERAPY AND MENTAL HEALTH COUNSELING APPLICATION FOR LIMITED LICENSURE and Instructions APPLICATION FOR LIMITED LICENSURE INSTRUCTIONS

More information

MARYLAND BOARD OF PROFESSIONAL COUNSELORS AND THERAPISTS 4201 PATTERSON AVENUE 316 BALTIMORE, MARYLAND 21215 410-764-4732 www.dhmh.maryland.

MARYLAND BOARD OF PROFESSIONAL COUNSELORS AND THERAPISTS 4201 PATTERSON AVENUE 316 BALTIMORE, MARYLAND 21215 410-764-4732 www.dhmh.maryland. MARYLAND BOARD OF PROFESSIONAL COUNSELORS AND THERAPISTS 4201 PATTERSON AVENUE 316 BALTIMORE, MARYLAND 21215 410-764-4732 www.dhmh.maryland.gov/bopc/ INSTRUCTIONS ALCOHOL AND OTHER DRUG COUNSELING OUT

More information

231 South Bemiston, Suite 1000 St. Louis, MO 63105 Email: submissions@galeninsurance.com

231 South Bemiston, Suite 1000 St. Louis, MO 63105 Email: submissions@galeninsurance.com 231 South Bemiston, Suite 1000 St. Louis, MO 63105 Email: submissions@galeninsurance.com LOCUM TENENS NEW BUSINESS APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE CLAIMS MADE COVERAGE INFORMATION REQUIRED

More information

MEDICAID N.C. - FORMS

MEDICAID N.C. - FORMS MEDICAID N.C. - FORMS 1. Exclusion Sanction questionnaire (A-K): Answer all questions: if you answer YES, you must attach a list with the date of each incident and also supporting documentation for each

More information

Kentucky Board of Medical Licensure 310 Whittington Parkway, Suite 1B Louisville, KY 40222 (502) 429-7150

Kentucky Board of Medical Licensure 310 Whittington Parkway, Suite 1B Louisville, KY 40222 (502) 429-7150 Kentucky Board of Medical Licensure 310 Whittington Parkway, Suite 1B Louisville, KY 40222 (502) 429-7150 M E M O R A N D U M TO: FROM: RE: Applicants for Surgical Assistant Certification Dawn Beahl, Surgical

More information

LIBERTY DENTAL PLAN Provider Credentialing Application

LIBERTY DENTAL PLAN Provider Credentialing Application (Complete one application per Provider) (* Required Fields) Credentialing Information: Owner: Associate: *PROVIDER NAME: DDS DMD Other (specify) *DATE OF BIRTH: / / Gender: Male Female Owning Dentist Name:

More information

Type of Facility (As listed on License or Accreditation) Facility Demographics. Legal Business Name (as reported to the IRS):

Type of Facility (As listed on License or Accreditation) Facility Demographics. Legal Business Name (as reported to the IRS): Facility Credentialing and Recredentialing Application Please complete each section leaving no blank spaces. Clearly state if information requested is not applicable. Attach additional sheets when necessary.

More information

MARYLAND BOARD OF PROFESSIONAL COUNSELORS AND THERAPISTS 4201 PATTERSON AVENUE 316 BALTIMORE, MARYLAND 21215 410-764-4732 www.dhmh.state.md.

MARYLAND BOARD OF PROFESSIONAL COUNSELORS AND THERAPISTS 4201 PATTERSON AVENUE 316 BALTIMORE, MARYLAND 21215 410-764-4732 www.dhmh.state.md. MARYLAND BOARD OF PROFESSIONAL COUNSELORS AND THERAPISTS 4201 PATTERSON AVENUE 316 BALTIMORE, MARYLAND 21215 410-764-4732 www.dhmh.state.md.us/bopc/ INSTRUCTIONS ALCOHOL AND OTHER DRUG COUNSELING OUT OF

More information

NASI Per Diem Malpractice

NASI Per Diem Malpractice Dear Nurse Anesthetist, We appreciate your interest in NASI s Per Diem Malpractice Insurance. This service is for those providers who need a supplemental policy for working an assignment outside of their

More information

INSTRUCTIONS FOR APPLICANTS WHO HOLD NBRC CERTIFICATION

INSTRUCTIONS FOR APPLICANTS WHO HOLD NBRC CERTIFICATION Email: st-medicine@pa.gov st-osteopahtic@pa.gov Medicine 717-783-1400/717-787-2381 Osteopathic 717-783-4858 APPLICATION FOR LICENSURE AS A RESPIRATORY THERAPIST This application can be used for licensure

More information