PARTICIPATING PROVIDER CREDENTIALING APPLICATION PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS

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1 Tips to avoid processing delays: APPLICATION SIGNATURE: THE FOLLOWING PAGES MUST BE SIGNED 10, 12 & 13. SECTION 1A. APPLICANT/PROVIDER INFORMATION Last Name (paternal) Last Name (maternal) First MI Date of Birth (MM/DD/YY) License State Membership (Colegiación) DEA (Licencia Narcóticos Federal) ASSMCA (Licencia Narcóticos Estatal) Number: Number: YES: Number: YES: Number: Exp. Date: (mm/dd/yy) Social Security Number: Medicare #: Individual NPI: Exp. Date: (mm/dd/yy) N/A Expiration Number: Expiration Number: NO NO CLIA (If Applicable) Male Female Number: Exp. Date: (mm/dd/yy) If YES please provide Address Are you part of any Group? YES NO Name NPI 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) Credentialing Contact Person Telephone Number: Credentialing Contact Person address: Do you perform e-prescribing? YES NO Do you have electronic records at your practice office? YES NO SECTION 1B. CORRESPONDENCE ADDRESS This information will be used if it needs to contact you directly. This address cannot be a billing agency s address. Mailing Address Line 1 (Street Name and Number): Mailing Address Line 2 (Suite, Room, etc.) City / Town City: State: Zip Code: Telephone: Fax: Address (if applicable): SECTION 1C. - PRACTICE INFORMATION 1. Do you perform home visits? If, Complete 1C1. If, proceed to Section 1C2. 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 Zip Page 1 of 16

2 SECTION 1C2. - PRACTICE OFFICE INFORMATION (OFFICE 1) Primary Office Address (Street Name and Number) : City: State: Zip Code: Practice Name (if applicable) Telephone: Fax: Name and Title of Contact Person (if other than provider) Contact Person Phone Number Contact Person Fax Number 1C3 MEDICAL STORAGE FACILITY Medical Record Storage Facility (Check One): Same as Physical If no, please complete below, and please indicate for Current Patients Former Patients Both Current and Former Patients Storage Facility Address Line 1 (Street Name and number): Storage Facility Address Line 2 (Suite or Room): City/Town: State: Zip Code Telephone Number: Fax Number: Address: 1C3 - PRACTICE OFFICE HOURS Office Hours Monday Tuesday Wednesday Thursday Friday Saturday AM Hours PM Hours SECTION 1D. ADDITIONAL OFFICES, COMPLETE THE FOLLOWING AREA (OFFICE 2) (For additional offices, make copies of this section, complete and submit) Primary Office Address (Street Name and Number) : City: State: Zip Code: Practice Name (if applicable) Telephone: Fax: Name and Title of Contact Person (if other than provider) Contact Person Phone Number Contact Person Fax Number 1D1 MEDICAL STORAGE FACILITY Medical Record Storage Facility (Check One): Same as Physical If no, please complete below, and please indicate for Current Patients Former Patients Both Current and Former Patients Storage Facility Address Line 1 (Street Name and number): Storage Facility Address Line 2 (Suite or Room): City/Town: State: Zip Code: Telephone Number: Fax Number: Address (If Applicable): 1D2 - PRACTICE OFFICE HOURS Office Hours Monday Tuesday Wednesday Thursday Friday Saturday AM Hours PM Hours Page 2 of 16

3 SECTION 1E. EMPLOYEES INFORMATION (For additional employees, make copies of this section, complete and submit information) Employee Roster must include first name and two last names for all Managing Employees, which means a general manager, business manager, administrator, director, or other individual that exercises operational or managerial control over, or who directly or indirectly conducts, the dayto-day operation of the institution, organization or agency ether under contract or through some other arrangement, whether or not the individual is a W-2 employee (42 CFR ). Roster needs to include list of healthcare professionals rendering services. Name (Father's last name, Mother's last name, First Name, MI) Title Professional License # (if applicable) Professional License Exp. Date (if applicable) 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? N/A If you answered or N/A to the question above please proceed to next Section below, if you answered,, continue below. Do you have any medical equipment that you use as part of your practice?. If please fill Attachment I. 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?. If, provide a list of such equipment. (Attachment III) SECTION 1G. - HIGHEST LEVEL OF EDUCATION Highest Level of Education Name: Highest Level of Education Address: Graduation Date (mm/dd/yy): Specialty Attained (Highest Level): Are you a foreign medical school graduate and have an ECFMG Certificate? If - ECFMG number: Is certified for Acupuncture? Serves patients with Autism? 1G1 BOARD CERTIFICATION ABMS Board Certification Specialty: Expiration Date: ABMS Board Certification Specialty: Expiration Date: Page 3 of 16

4 SECTION 1H - WORK HISTORY (Please submit the minimum of the last five Years of Medical Practice History) Location (Physical Address of Primary Office Address) From (mm/yr.) To Present Location (Physical Address) From (mm/yr.) To (mm/yr.) Location (Physical Address) From (mm/yr.) To (mm/yr.) Location (Physical Address) From (mm/yr.) To (mm/yr.) Location (Physical Address) 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: SECTION 1I. - CLINICAL PRIVILEGES Do you have clinical Privileges?, If skip to next section. If, list the name (s) of an in network physician or facility below: Hospital/Group Name Location Active Pending Hospital/Group Name Location Active Pending SECTION 1J. - CLINICAL REFERRAL Please list all clinic referral affiliations (hospital, clinics, groups, PHO/IPAs, etc.) or covering physicians: Hospital/Group/Clinic Name Location Associate Provisional Associate Provisional N/A Courtesy Staff Courtesy Staff Hospital/Group/Clinic Name Location 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? If you answered yes to the previous question, please explain: SECTION 1L. - PROFESSIONAL LIABILITY INSURANCE Have you ever been denied professional liability insurance or has your coverage ever been cancelled or not renewed. If, please explain SECTION 1N. - COMPLETE PROFESSIONAL LIABILITY INSURANCE INFORMATION Present Carrier s Name Policy Number Policy Limits / Effective Dates mm/dd/yy (From) (To) Page 4 of 16

5 SECTION 2. - PROVIDER QUESTIONNAIRE FINAL ADVERSE LEGAL ACTIONS / CONVICTIONS SECTION 2.A QUESTIONS RELATED TO APPLICANT/PROVIDER Do you now or have you ever had a chemical dependency, substance abuse, alcohol or drug problem, treated or untreated, which in any way impairs your ability to practice to the fullest extent of your licensure and qualifications or in any way poses a risk of harm to your patients? 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? If to any above questions, please specify below: SECTION 2.B - INFORMATION ON PERSONS CONVICTED OF CRIMES- This section captures FINAL ADVERSE ACTIONS- INFORMATION OF PERSONS CONVICTED OF CRIMES- OF APPLICANT/ PROVIDER. Answer the following questions by checking "" or "". If any of the questions are answered "", COMPLETE in spaces provided. This section captures information on final adverse actions, such as convictions, exclusions, revocations, and suspensions. All applicable final legal actions must be reported, regardless of whether any records were expunged or any appeals are pending. See explanation below. List any additional names and addresses on the proper section of the sheet provided. 1. 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 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? G. Ever been convicted of any crime (excluding traffic or parking violations) or pending any litigation for an alleged crime? H. Ever been convicted of a crime under the Criminal Control Act or are you currently under indictment for an alleged crime? I. Ever lost, revoke or suspend your DEA or AMSSCA license? 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 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

6 Full Name of Organization (Legal Business Name) or Full Name of Individual (First and Last Names) Check Applicable Program-Agency of Licensing Authority State EFFECTIVE DATE(S) OF Conviction, Exclusion, Revocation or Suspension (Month/Day/Year) DATE(s) OF REINSTATEMENT(s) (If Any) (Month/Day/Year) Medicaid Medicare Other: Specify: 2B.1a TYPE OF OFFENSE AND DISPOSITION: ADDITIONAL SPACE FOR SECTION 2B.1 Full Name of Organization (Legal Business Name) or Full Name of Individual (First and Last Names) Check Applicable Program Medicaid Medicare Other: Specify: TYPE OF OFFENSE AND DISPOSITION: State EFFECTIVE DATE(S) OF (Conviction, Exclusion, Revocation or Suspension) Month/Day/Year DATE(s) OF REINSTATEMENT(s) (If Any) Month/Day/Year 2C MEDICARE, MEDICAID, TITLE V OR TITLE XX PARTICIPATION Do you the Applicant/Provider, currently participate or has this entity ever participated, as a provider in a Medicare, Medicaid, TITLE V or Title XX Program in Puerto Rico or another state? If yes, provide information in Section 2C.1; If, proceed to section 2D 2C.1 Please list individuals 2C: Full Name of Organization (Legal Business Name) or Full Name of Individual (First and Last Names) State Name(s) (Legal and DBA) NPI and/or Provider Number State Name(s) (Legal and DBA) NPI and/or Provider Number State Name(s) (Legal and DBA) NPI and/or Provider Number 2D DEBTS TO LOCAL OR STATE GOVERNMENT List below any fines/debts due and owing to any federal, state or local government program or agency (ex. Medicare, Medicaid, Title V or Title XX) that have not been paid and what arrangements have been made to fulfill the obligation (s). If yes, provide information in Section 2D.1, If NO, proceed to next Section. 2D.1 Please list information 2D AND submit copies of all documents pertaining to the arrangements including terms and conditions. Fine/Debt Agency Date Issued (Month/Day/Year) Date to be Paid in Full (Month/Day/Year) $ $ Address (Street Name or Suite and Number) City State Zip Code Medicare Identification Number Tax identification number (Required) NPI Page 6 of 16

7 SECTION 3. DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST INFORMATION (42 CFR ; 42 CFR ) According to the Code of Federal Regulations title 42, part 455, sections AND part 420, sections , all providers enrolling with Medicaid and Medicare Advantage programs must complete a Provider Disclosure Statement. ALL PROVIDERS MUST COMPLETE THIS SECTION. Refer to Attachment II for instructions on how to complete this Section. Check one that most closely describes you: Individual Group Practice Disclosing Entity Name of Individual, Group Practice, or Disclosing Entity Address City State Zip Code Federal Tax Identification Number NPI Questions 1-3 to be answered by all providers 1. Has the provider, or any person who has ownership or control interest in the provider, or is an agent or managing employee of the provider ever been suspended, excluded, or debarred related to the person's involvement in any program under Medicare, Medicaid, or the Title XX program or convicted of a crime related to that person's involvement in any program under Medicare, Medicaid, or the Title XX program? If yes, list the name(s) of person(s). (42 CFR ) (Should be verified through appropriate HHS-EPLS-OIG website). YES NO A. NAME TITLE ADDRESS DESCRIPTION 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 ). If response is NO, continue to question #3. YES NO A. B. C. D. NAME ADDRESS 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 ) N/A A. B. C. D. NAME ADDRESS Page 7 of 16

8 3. Has the provider had any significant business transactions with any wholly owned supplier or with any subcontractor during the preceding five-year period? If yes, give the information below for each wholly owned supplier or subcontractor. (42 CFR ) A. B. C. D. YES NAME ADDRESS DESCRIPTION OF BUSINESS TRANSACTION NO 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 ) A. B. C. D. NAME ADDRESS 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 ) A. NAME RELATIONSHIP YES NO 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 ) YES NO A. B. C. D. NAME ADDRESS 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

9 SECTION 4. BILLING INFORMATION- This section captures information on PERSON (INDIVIDUAL) OR BILLING AGENCY that submits claims on behalf of provider. A Person (individual) or billing agency is a company or individual that you contract with to prepare and submit your claims. Ultimately, you are responsible for the claims submitted on your behalf. SECTION 4A. - BILLING PERSON OR AGENCY NAME AND ADDRESS Check One: Individual (Employee or Supplier/Applicant/Provider in Office (Complete 4A2) Individual not in office (Complete 4A2) Billing Agency (Complete 4A1) Sub-Contractor (If sub-contractor is a Billing Agency, complete 4A1 and If sub-contractor is an individual, complete 4A2) Other, Specify: (te: If the other box is checked as the option and it is an individual, complete 4A2) 4A1. BILLING AGENCY INFORMATION Legal Business Name (as Reported to Internal Revenue-Hacienda) Doing Business As (DBA) name (If applicable) Billing Agency Address (Street Name and Address) Tax ID Number or Social Security Number (required) Address (If Applicable) Telephone Number Fax Number (If Applicable) City State Zip Code 4A2. IF INDIVIDUAL IN OFFICE OR NOT IN OFFICE: Full Name and Title of Individual (include both paternal and maternal Last names): Telephone Number: Fax Number: Address (Street Name or Suite and Number) City State Zip Code Billing Person Date of Birth (mm/dd/yy) Social Security Number (required) 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

10 SECTION 5- PROVIDER PAYMENT INFORMATION Once we have finalized your credentialing process, we would need to know your payment information in order to have your payment sent to the correct address and payee. It is important to know that if you wish to have your checks payable to the Corporation or Group practice, that this practice has their own NPI and Tax Identification number. (Please sign below) Last Name (both): First Name: Middle Initial: Specialty: Date of Birth: TYPE OF PROVIDER: Individual Practice Group Practice Corporation If group is checked, please provide Name of Group: If Corporation is checked, please provide Name of Corporation: If Individual Practice is checked, please provide name of Individual: Last Names (Both): First Name: Middle Initial IF GROUP: List Tax ID number: Tax ID of Group or Tax ID Corporation: (Check one) (Corporation or Group) IF CORPORATION: NPI of Group or NPI Corporation: (Check one) List NPI Number: (Corporation or Group) IF INDIVIDUAL: NPI of Individual: (Check one) List NPI Number: (Individual) List S.S.Number: (Individual) Payee Address: City State ZIP Code Telephone number Fax number Name and Title of Contact Person (if other than provider) Contact Person Telephone Number Contact Person Fax Number Provider Name (Please Print) Provider Signature Date Page 10 of 16

11 SECTION 6. STANDARD AUTHORIZATION, ATTESTATION AND RELEASE OF INFORMATION REFER TO ATTACHMENT I LIST OF AUTHORIZED ORGANIZATIONS 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 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 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 entity s affiliated entities and their representatives, employees and/or designated agents; and the Entity s 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 Médica de Puerto Rico, Office of Personnel Management (OPM), and the Office of the Inspector General (OIG), to release to the Entity and/ór 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 party s 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

12 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 another consent may be grounds for termination or discipline by the entity in accordance with the applicable bylaws, rules, and regulations, and requirements of the entity, or grounds for my termination of participation at or with the entity. I agree that information obtained in accordance with the provisions of this Authorization, Attestation 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 current, true, correct, accurate and complete to the best of my knowledge and belief, and is furnished in good faith. I will notify the entity and /or its agent(s) within 30 days of any material changes to the information (including any changes/challenges to licenses, DEA, insurance, malpractice claims, NPDB/HIPDB reports, discipline, criminal convictions, etc.) 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 online or in writing, and must be dated and signed by me (may be a written or an electronic signature). I acknowledge that the entity will not process an application until they deem it to be a complete application and that I am responsible to provide a complete application and to produce adequate and timely information for resolving questions that arise in the application process. 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 or be subject to applicable state or federal penalties for perjury. This action may be disclosed to the entity and/or its agent(s). I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release and that I agree to abide by its terms, rules and regulations. I understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original. Provider Name (Please Print) Provider Signature Date Page 12 of 16

13 SECTION 7. CERTIFICATION STATEMENT REFER TO ATTACHMENT I LIST OF AUTHORIZED ORGANIZATIONS By signing, I, the undersigned, certify to the following: 1. 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 supplier s 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 Date Page 13 of 16

14 ATTACHMENT I LIST OF AUTHORIZED ORGANIZATIONS TRIPLE-S SALUD, INC, TRIPLE S- ADVANTAGE, INC. TRIPLE S- ADVANTAGE SOLUTIONS, INC. Page 14 of 16

15 ATTACHMENT II INSTRUCTIONS FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST (42 CFR ; 42 CFR ) According to the Code of Federal Regulations title 42, part 455, sections AND part 420, sections , all providers enrolling with Medicaid and Medicare Advantage programs must complete a Provider Disclosure Statement. The definitions below are designed to clarify certain questions on the Disclosure form. If you cannot report all of the necessary information in a designated section of the form because of space limitations, please provide the information on a separate paper. Definitions Agent means any person who has been delegated the authority to obligate or act on behalf of a provider. Disclosing entity means a Medicaid provider (other than an individual practitioner or group of practitioners), or a fiscal agent. 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. This includes: (a) Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (title XVIII); (b) Any Medicare intermediary or carrier; and (c) Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, healthrelated services for which it claims payment under any plan or program established under title V or title XX of the Act. Fiscal agent means a contractor that processes or pays vendor claims on behalf of the Medicaid agency. Group of practitioners means two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment). Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity. Individual practitioner means a physician or other licensed or certified under State law to practice his or her profession. Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency. Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity. Person with an ownership or control interest means a person or corporation that (a) Has an ownership interest totaling 5 percent or more in a disclosing entity; (b) Has an indirect ownership interest equal to 5 percent or more in a disclosing entity; (c) Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity; (d) Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity; (e) Is an officer or director of a disclosing entity that is organized as a corporation; or (f) Is a partner in a disclosing entity that is organized as a partnership. Significant business transaction means any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a provider's total operating expenses. Subcontractor means (a) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or (b) An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement. Supplier means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical firm). Wholly owned supplier means a supplier whose total ownership interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a provider. Page 15 of 16

16 ATTACHMENT III Provider Name NPI IMAGING PRODUCTION IN HOUSE AVAILABLE EQUIPMENT LISTING TYPE YES/NO 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