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

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1 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 Code: County: Billing Address (if different from above): City: State: Zip Code: County: Chief Executive Officer or Administrator s Name: Facility Phone Number: Facility Fax Number: Credentialing Contact: Phone Number: Fax Number: Medicare Provider Number: Facility Tax I.D. Number: NPI Number: Medicaid Provider Number: Facility Address: OWNERSHIP INFORMATION Please check all that apply and provide copies Corporation For Profit Hospital Joint Venture Physician/Hospital owned 100% Physician Owned 100% Phys./RPT owned Not For Profit Sole Proprietorship Other 100% Hospital owned HOFF (Hospital owned free standing facility) 1

2 LICENSURE INFORMATION Please check all that apply and provide copies City/County Business Tax Receipt Dept. of Children and Family Services Exempt from Licensure (100% owned) Pharmacy Radioactive Material License State of Florida (AHCA) SERVICES Acute Care/Long Term Hospital Ambulatory Infusion Suite Birthing Center Comprehensive Outpatient Rehab Ctr. Crisis Stabilization Unit Federally Qualified Health Centers Home Health Agency Home Infusion / Injectable Supplier Hospice Independent Diagnostic Testing Facility Mobile Lithotripsy Orthotics /Prosthetics Physical Therapy Group Psychiatric Hospital / Unit Rural Health Center Sleep Center Substance Abuse Facility Urgent Care Center Ambulance Ambulatory Surgery Center Community Mental Health Center Convenient Care Center Dialysis Hearing Aid Center Home Infusion and Ambulatory Suite Home Medical Equipment Independent Clinical Laboratory Medical Supply Company Optical Company Outpatient Rehabilitation Facility Portable X Ray Residential Treatment Facility Skilled Nursing Facility / Unit Specialty Pharmacy 2

3 ACCREDITATIONS AND CERTIFICATIONS Please check all that apply and provide copies AAAHC AMERICAN ASSOCIATION FOR AMBULATORY HEALTH CARE ACHC ACCREDITATION COMMISION FOR HEALTH CARE ABCOP AMERICAN BOARD FOR CERTICATIONS IN ORTHOTICS, PROSTHETICS & PEDORTHICS ACR AMERICAN COLLEGE OF RADIOLOGY CARF COMMISION ON ACCREDITATION OF REHABILITATION FACILITIES CLIA CLINICAL LABORATORY IMPROVEMENT ACT COLA COUNCIL ON LABORATORY ACCREDITATION CAP COLLEGE OF AMERICAN PATHOLOGY CHAP COMMUNITY HEALTH ACCREDITATION PROGRAM FDA FOOD AND DRUG ADMINSTRATION REQUIRED: IF PERFORMING MAMMOGRAPHY SERVICES JCAHO NOW KNOWN AS THE JOINT COMMISSION CABC COMMISION FOR THE ACCREDITATION OF BIRTH CENTERS COA COUNCIL ON ACREDITATION HQAA HEALTHCARE QUALITY ASSOCIATION ON ACCREDITATION NBAOS NATIONAL BOARD OF ACCREDITATION FOR ORTHOTIC SUPPLIERS NIAHO NATIONAL INTERGRATED ACCREDITATION FOR HEALTHCARE ORGANIZATIONS AASM AMERICAN ACADEMY OF SLEEP MEDICINE BOCUSA BOARD OF CERTIFICATION / ACCREDITATION INTERNATIONAL MEDICARE CERTIFICATION if applicable BUREAU OF RADIATION CONTROL REGISTRATIONS (JR no.) if applicable IAC INTERSOCIETAL ACCREDITATION COMMISSION OTHER STATUS WITH REGULATORY AGENCIES 1. Has this facility s license and/or certification(s) ever been subject to any inquiries (including investigation or notice of intent to investigate) and/or any sanctions, suspensions, limitations or revoked by any state, federal or regulatory agency? Yes No If yes, please explain or provide an explanation: 3

4 2. Has this facility ever been subject to restrictions on receipt of payment from Medicare or Medicaid? Yes No If yes, please explain or provide an explanation: 3. Has this facility had within the past five years, or currently pending, any malpractice claims, suits, settlements or arbitration proceedings involving your facility? Yes No If yes, please explain or provide an explanation: LIABILITY COVERAGE Please provide copies of all with limits of liability, coverage amounts, effective and expiration dates. GENERAL LIABILITY CERTIFICATE OF INSURANCE COVERAGE: YES NO PROFESSIONAL LIABILITY CERTIFICATE OF INSURANCE COVERAGE: YES NO EMPLOYERS CERTIFICATE OF LIABILITY COVERAGE required for Ambulance: YES NO AUTOMOBILE CERTIFICATE OF LIABILITY COVERAGE required for Ambulance: YES NO 4

5 **For Independent Diagnostic Testing Facilities ONLY complete the section below before submitting** Physicians Supervisory Certification Statement I hereby acknowledge the fact that I agree to provide (insert IDTC name) physiological lab with general physician supervisory responsibilities in the areas of non invasive and diagnostic services. The supervisory responsibilities include, but may not be limited to, verifying periodically that equipment is functioning properly and produces the quality of results expected from similar equipment. The physician also assumes responsibility for following, on a continuous basis, those technicians performing non invasive and diagnostic testing and assisting them with any problems they encounter while providing such services. It also includes giving direction and recommendations to management on an ongoing basis regarding proper training or refresher training for those technicians performing the testing. Physicians Name (Please type or print) Physicians Signature Florida License Number Date If performing advanced imaging services, please check all that applies and provide supporting copies of accreditation: MRI CT PET NC (includes cone beam CT) 5

6 ATTACHMENTS 1. Current copy of General and Professional Liability coverage limits of liability, coverage and effective and expiration dates 2. Copy of State License if applicable 3. Copy of Occupational or Business Tax Receipt License if applicable 4. Current copy of Medicare Certification if applicable 5. Copy of Accreditation/Certifications if applicable 6. ACR/FDA Certificates/ Documentation of Tube Registrations 7. Copy of Medicare Participation Agreement if applicable 8. Copy of Medicaid Certificate if applicable 9. Copy of Facility s Medical Director or Director of Nursing CV applicable to Home Health 10. Copy of Medical License, Professional Liability and DEA applicable to Urgent Care Center 11. Copy of most recent AHCA and/or CMS Medicare Site Survey Report if applicable ATTESTATION I HEREBY CERTIFY that the preceding information is true and complete. I give my permission to Florida Blue and its affiliates to contact any and all persons or entities to verify these facts. I agree there shall be no liability on the part of, and no action for damages shall arise against, Florida Blue or its affiliates, its representatives, or any individuals or entities providing information in good faith related to the evaluation or verification of the information contained in this application. I also certify that I hold a full unrestricted license in the state in which this facility operates (if applicable), as well as, agree to maintain current malpractice coverage. I will immediately inform Florida Blue of any changes to the above information. I acknowledge and agree that any contract that may be entered into with Florida Blue and/or any affiliates based on this application may, at the option of Florida Blue, be deemed void and ineffective if any of the preceding information is not complete, true and correct. Signature of Facility Representative: Date: 6