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

Size: px
Start display at page:

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

Transcription

1 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 the delivery of health care and services to our members. UUHP is committed to the triple aim of improving experience and quality of care, improving the health of populations, and reducing the per capita cost of care. We recognize the importance of population health and payment reform and have developed extensive care management and value-based payment programs that improve health and align provider reimbursement with value and positive outcomes. Provider applications to participate in any UUHP network are considered based on 1) network adequacy, 2) business needs and 3) the credentialing process. All providers must be approved through our credentialing process before they may participate in any network. The University of Utah Health Plans offers the following plans and networks. Please specify the networks you are interested in participating with: Healthy U: A Medicaid Accountable Care Organization (ACO) plan and network available to eligible Medicaid members in Box Elder, Cache, Davis, Morgan, Salt Lake, Summit, Tooele, Utah, Wasatch and Weber counties. Healthy Advantage: A Medicare Special Needs plan and network for individuals who qualify for Medicare and Medicaid in Salt Lake, Davis, Weber and Utah counties. H.O.M.E.: A Coordinated Healthcare Model, in partnership with the University Neuropsychiatric Institute, to meet the medical and mental health needs of people with developmental disabilities. Healthy Advantage Plus: A Medicare Advantage HMO plan and network available for eligible Utah Seniors in Salt Lake, Davis, Weber and Utah counties. Healthy Premier: A statewide commercial network offered to employer groups and individuals. Healthy Preferred: A commercial narrow network along the Wasatch Front available to employer groups. For consideration in any UUHP network, please fill out the attached application form and return to UUHP via , provider.relations@hsc.utah.edu, or fax, , and include the following: Page 1

2 1. A copy of your W-9 IRS Tax form. A copy of your current Utah Business License. 3. A copy of your Utah State Medicaid approval letter. 4. A copy of your Medicare acceptance letter, or certificate. 5. A copy of your current Certificate of Insurance Liability. 6. An Electronic Data Interchange (EDI) number or EDI clearing house. If you do not furnish these 6 requested documents, your application may be withdrawn. University of Utah Health Plans evaluates provider network applications in accordance with its credentialing policy and criteria, as well as business needs for the particular network. Business needs may include and are not limited to: Network adequacy requirements based on state and/or federal guidelines Network adequacy requirements based on the current or expected population of a given geographic area (usually defined by county or zip code) Network adequacy requirements based on provider type and/or specialty Network composition based on scope of services required by payer such as employer, health plan, union/trust, government entity, etc. Network performance requirements in terms of cost/utilization, quality measures, outcomes, access, and/or patient or physician satisfaction. Demographic needs including but not limited to languages spoken Existing, non-compensated, referral patterns with current network providers and/or UUHP members Benefits of participating with a UUHP network include: Claim payments made to you directly on a weekly basis. Provider Relations representatives are available to help you and your staff. Inclusion in UUHP s on-line and printed provider directories made available to brokers, employers and members for the applicable products. Member benefits are designed to encourage use of network providers. Participation with U Link an online tool to verify eligibility, check claims status, submit inquiries, etc. Completion of this application does not guarantee a contract or participation with the University of Utah Health Plans. The University is a governmental entity and thus subject to the Utah Government Records Access and Management Act, Utah Code Ann., Sec et seq., as may be amended ( GRAMA ); that certain records within University s possession or control, including without limitation may be subject to public disclosure; and that University s confidentiality obligations shall be subject in all respects to compliance with GRAMA. Pursuant to Section 63G of GRAMA, University hereby informs that any person or entity that provides University with records that such person or entity believes should be protected from disclosure must be accompanied by a written claim of confidentiality and a concise statement of reasons supporting such claims. Page 2

3 Application Form Please give a brief description of your services or scope of practice, in the space below: (You may attach your marketing material.) Office / Business Information (Group & Individual NPI numbers must be registered with Utah Medicaid) Group Name Specialty(s) Group NPI Group Tax ID Clinic # 1 Billing (Please include a copy of your W-9) Clinic Phone Number Billing Phone Number Clinic Billing Clinic Facsimile Name of Clinic Administrator Clinic Administrator Phone Number Billing Facsimile Electronic Data Interchange Number (EDI) EDI Billing Service or Clearing House Page 3

4 Provider Information Provider # 1 5. Provider # 2 5 Provider # 3 5. Provider # 4 5. (If more than 2 clinics and /or more than 4 providers, please copy this page and submit) Please to: provider.relations@hsc.utah.edu, or fax to: (801) Page 4

5 Provider Information Each applicant must complete questionnaire (please make copies if necessary) NAME: Minimum Requirement for all Applicants Do you have any current Medicare or Medicaid sanction(s)? Have you ever had a license to practice revoked, suspended or placed on probation by any state licensing agency? Have you ever been convicted of any felony, or of any misdemeanor relating to the practice of medicine? Yes No If you have answered YES to any of the above questions, you may be ineligible to be a participating provider. Please contact UUHP Provider Relations at (801) Do you have a current license to practice in the State of Utah? Do you have professional Liability Insurance? Physicians Only. Have you successfully completed an internship and residency program approved by the American College of Graduate Medical Education or the American Osteopathic Association? Physicians Only. Have you successfully graduated from an accredited School of Medicine, Osteopathy, Podiatry or Dentistry? Physicians Only. Do you have a current DEA license and State Controlled Substance license? Physicians Only. Have you ever had medical staff appointments denied, revoked, resigned, relinquished or terminated by any health care facility or health plan, for reasons related to clinical competence or professional conduct? Physicians Only. Are you board admissible, board certified, completing the last six months of an approved residency program of at least three (3) year s duration, or in the process of becoming board certified? Physicians Only. Do you have malpractice insurance in the amount of $1,000,000 for each occurrence? Physicians Only. Do you have malpractice insurance in the amount of $3,000,000 in the annual aggregate or greater? Page 5

6 ATTESTATION / CONSENT / RELEASE (Per Provider) The information contained herein and the attached documents contain detailed and specific information relating to my character and professional competence. I warrant that all of the information that I have provided and the responses that I have given are correct and complete to the best of my knowledge and belief. I understand that any misrepresentation and/or any significant omissions in this application constitute cause for denial or for subsequent revocation of membership and privileges. By applying for appointment to the facility or health plan and for the exercise of specific clinical privileges, I hereby authorize the facility or health plan, its medical staff, and its authorized agents to investigate and evaluate my provider application, and consult with any person, organization, or entity that has, or could have any information, data, or documents regarding my background, competence, credentials, character and ethical qualifications. I further authorize the transmission of this application and all supporting documentation, and all information collected during the credentialing process, to each and every component of the participating healthcare entities in which I have sought membership, privileges or other status, and I further fully authorize the release of that documentation or information to any hospital, medical staff, medical group or other health care entity that may seek it as part of an authorized credentialing or peer review process. I hereby fully release from liability all representatives of the facility or health plan, its medical staff, and its authorized agents for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I hereby release from liability any and all individuals and organizations who provide information to the facility or health plan or its medical staff, or authorized agents in good faith and without malice, concerning my professional competence, ethics, character and other qualifications for staff appointment and clinical privileges, and I hereby consent to the release of such information. If applicable for the healthcare entity that I am applying, I further consent to the obtaining of a criminal background check. During the time that this application is being processed, I agree to update the application should there be any material change in the information provided which may affect the application or its outcome, and I specifically agree to notify the specified entities to which I am applying immediately upon notification of any significant or formally recommended change in licensure status, or any actual or formally recommended denial, suspension or revocation of privileges or membership with another healthcare entity, or cancellation or interruption of my professional liability insurance coverage. I attest that all information submitted by me in this application is true, current and complete and furnished in good faith. Signature: Date: Printed Name: Page 6

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

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

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

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

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

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

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

Community Health Group Allied Health Professional Application

Community Health Group Allied Health Professional Application Community Health Group Allied Health Professional Application Nurse Practitioner Certified Nurse Midwife LCSW Clinical Psychologist MFCC Other I. INSTRUCTIONS This form should be typed or legibly printed

More information

Community Health Group Physician Application

Community Health Group Physician Application Community Health Group Physician Application I. INSTRUCTIONS This form should be typed or legibly printed in black or blue ink. If more space is needed than provided on original, attach additional sheets

More information

ANCILLARY PROVIDER APPLICATION FOR PARTICIPATION PHYSICIANS HEALTH PLAN PO Box 30377, Lansing, MI 48909-7877 517.364.8312

ANCILLARY PROVIDER APPLICATION FOR PARTICIPATION PHYSICIANS HEALTH PLAN PO Box 30377, Lansing, MI 48909-7877 517.364.8312 ANCILLARY PROVIDER APPLICATION FOR PARTICIPATION PHYSICIANS HEALTH PLAN PO Box 30377, Lansing, MI 48909-7877 517.364.8312 INSTRUCTIONS: Please provide answers to all questions. If the answer is none, or

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

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

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

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

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

Instructions For Completing The California Participating Physician Application

Instructions For Completing The California Participating Physician Application Instructions For Completing The California Participating Physician Application To effectively use the Application, the following is suggested: Type or legibly complete the Application in black or blue

More information

Terrebonne General Medical Center 8166 Main Street Houma, Louisiana 70360 Human Resources (985) 873-4628 Phone 985-873-4481 Fax

Terrebonne General Medical Center 8166 Main Street Houma, Louisiana 70360 Human Resources (985) 873-4628 Phone 985-873-4481 Fax Terrebonne General Medical Center 8166 Main Street Houma, Louisiana 70360 Human Resources (985) 873-4628 Phone 985-873-4481 Fax APPLICATION FOR APPOINTMENT TO THE NON-CLINICAL ALLIED HEALTH STAFF Instructions

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

Name: Last First Middle Suffix Title. Date of Birth: / / Social Security Number: NPl:

Name: Last First Middle Suffix Title. Date of Birth: / / Social Security Number: NPl: Minnesota Uniform Dental Initial Credentialing Application CREDENTIALING CONTACT INFORMATION (please provide contact information If you would like us to contact someone other than you (the provider) in

More information

PHYSICIAN PRE-APPLICATION CENTRAL FLORIDA PHYSICIANS ALLIANCE, INC. A Physician Owned Independent Practice Association Serving Central Florida

PHYSICIAN PRE-APPLICATION CENTRAL FLORIDA PHYSICIANS ALLIANCE, INC. A Physician Owned Independent Practice Association Serving Central Florida Place you r m essag e h ere. Fo r m axim um i mpact, use two or t hre e se ntenc es. PHYSICIAN PRE-APPLICATION CENTRAL FLORIDA PHYSICIANS ALLIANCE, INC. Heading A Physician Owned Independent Practice Association

More information

PERSONAL DATA NOTE: SHADED PORTIONS N/A TO ALLIED HEALTH PROFESSIONALS. 1. Name. 2. Other Name(s) Previously Used Effective

PERSONAL DATA NOTE: SHADED PORTIONS N/A TO ALLIED HEALTH PROFESSIONALS. 1. Name. 2. Other Name(s) Previously Used Effective For Credentialing Staff Use Only Specialty Date Application Received Attach a recent 2 x 2 passport size photograph for the master file and each facility marked on this application Date Application Signature

More information

TEMPLE UNIVERSITY HOSPITAL

TEMPLE UNIVERSITY HOSPITAL u TEMPLE UNIVERSITY HOSPITAL INSTRUCTIONS FOR APPLYING FOR EMERGENCY TEMPORARY PRIVILEGES FOR NON-APPLICANTS (these privileges are for care of patients during and emergency disaster) ************************************************************************

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

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 EFFECTIVE DATE: 10/04 Applies to all products administered by the plan except when changed by contract Policy Statement:

More information

PERSONAL DATA. 1. Name. 2. Other Name(s) Previously Used Effective Date. 3. Social Security Number 4. UPIN# 5. Medicaid #

PERSONAL DATA. 1. Name. 2. Other Name(s) Previously Used Effective Date. 3. Social Security Number 4. UPIN# 5. Medicaid # For Credentialing Staff Use Only Specialty Date Application Received Attach a recent 2 x 2 passport size photograph for the master file and each facility marked on this application Date Application Signature

More information

Blue Cross Blue Shield of Arizona Dental Provider Contracting Request and Information Form

Blue Cross Blue Shield of Arizona Dental Provider Contracting Request and Information Form . Blue Cross Blue Shield of Arizona Dental Provider Contracting Request and Information Form Thank you for your interest in becoming a contracted dental provider. In order to be considered for a contract

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

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

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

A HELPFUL TIP ON COMPLETING THIS FORM:

A HELPFUL TIP ON COMPLETING THIS FORM: A HELPFUL TIP ON COMPLETING THIS FORM: For your convenience, you may find it useful to complete this form by typing in the form fields of this PDF file before printing it out. The result will be cleaner

More information

6325 Hospital Parkway Johns Creek, Georgia 30097 Phone 678-474-7000 emoryjohnscreek.com Dear Provider,

6325 Hospital Parkway Johns Creek, Georgia 30097 Phone 678-474-7000 emoryjohnscreek.com Dear Provider, Dear Provider, Thank you for your recent inquiry in credentialing at Emory Johns Creek Hospital. Through our affiliation with Emory Healthcare, we are pleased to announce that our application process is

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

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

CREDENTIALING PROCEDURES MANUAL

CREDENTIALING PROCEDURES MANUAL CREDENTIALING PROCEDURES MANUAL Page PART I Appointment Procedures 1 PART II Reappointment Procedures 5 PART III Delineation of Clinical Privileges Procedures 7 PART IV Leave of Absence, Reinstatement,

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

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

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

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

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

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

In addition to the completed application, we will need the following:

In addition to the completed application, we will need the following: Thank you for your interest in becoming a Consociate Care Network Provider. In addition to the completed application, we will need the following: Copy of CV Copy of medical license Copy of DEA license

More information

CREDENTIALING POLICY OF UNIVERSITY OF UTAH HOSPITAL AND CLINICS

CREDENTIALING POLICY OF UNIVERSITY OF UTAH HOSPITAL AND CLINICS CREDENTIALING POLICY OF UNIVERSITY OF UTAH HOSPITAL AND CLINICS Revised November, 2004 TABLE OF CONTENTS PAGE 1. DEFINITIONS...1 1.A DEFINITIONS...1 1.B TIME LIMITS...2 1.C DELEGATION OF FUNCTIONS...2

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

Dental Provider Application

Dental Provider Application Dental Provider Application Dental Application Instructions To apply for participation, please fill out the enclosed application, completing all appropriate sections and providing all required materials.

More information

Professional Liability Insurance Application Claims Made Basis. Short Form

Professional Liability Insurance Application Claims Made Basis. Short Form Preferred Professional Insurance Company Professional Liability Insurance Application Claims Made Basis Short Form IMPORTANT INSTRUCTIONS - PLEASE READ CAREFULLY 1. PLEASE MAKE SURE ALL QUESTIONS ARE ANSWERED

More information

INITIAL CREDENTIALING APPLICATION

INITIAL CREDENTIALING APPLICATION Attn: Fax #: Phone #: INITIAL CREDENTIALING APPLICATION Dear Provider: To participate in our Sierra Health Services network, all practitioners must complete our credentialing process prior to contracting.

More information

Instructions. 4) Copy of IRS documentation (i.e. Letter 147T or 147C, Federal Deposit Coupon, ETPS, or Letter CP575).

Instructions. 4) Copy of IRS documentation (i.e. Letter 147T or 147C, Federal Deposit Coupon, ETPS, or Letter CP575). Instructions If applying for a provider number with Blue Cross Blue Shield of Alabama, Blue Cross needs the following information completed and returned to us by mail or fax. This information is needed

More information

Doctors Hospital Allied Health Professional Application for Appointment

Doctors Hospital Allied Health Professional Application for Appointment Doctors Hospital Allied Health Professional Application for Appointment Applying for the following job (please check): Allied Health Delineation of Privileges Allied Health Scope of Practice Category 1

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

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

Merced County Department of Mental Health P.O. Box 2087 Merced, CA 95344 MEDI-CAL NETWORK PROVIDER APPLICATION

Merced County Department of Mental Health P.O. Box 2087 Merced, CA 95344 MEDI-CAL NETWORK PROVIDER APPLICATION Merced County Department of Mental Health P.O. Box 2087 Merced, CA 95344 MEDI-CAL NETWORK PROVIDER APPLICATION Merced County Department of Mental Health P.O. Box 2087 Merced, CA 95344 Phone: (209) 381-6800

More information

Clinician Add/Change Application Form

Clinician Add/Change Application Form Clinician Add/Change Application Form INSTRUCTIONS (1) Before completing this form, it is essential to review your current demographic information online to ensure that the requested changes align with

More information

MEDICAL STAFF POLICY & PROCEDURE

MEDICAL STAFF POLICY & PROCEDURE 240 Maple Street PO Box 470 Woodruff, WI 54568 (715) 356-8000 MEDICAL STAFF POLICY & PROCEDURE NUMBER: MS.4 EFFECTIVE/APPROVAL DATE: TITLE: CREDENTIALING POLICY REVISION DATE: 4/97; 1/98; 7/98; 2/99; 12/00;

More information

Independent Contractor Application for NP/PA

Independent Contractor Application for NP/PA Personal Information First Name Last Name Middle Name Suffix Home Phone Work Phone Cell Phone Email Address Date of Birth (mm/dd/yyyy) Place of Birth (City, State, Country) SSN Are you legally able to

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

PROVIDER CREDENTIALING APPLICATION

PROVIDER CREDENTIALING APPLICATION PROVIDER CREDENTIALING APPLICATION We appreciate your interest in becoming a TRICARE network provider, offering medical services for Prime Beneficiaries. Please read this instruction sheet carefully before

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

Texas Credentialing Application Checklist

Texas Credentialing Application Checklist APPLICANT NAME: Texas Credentialing Application Checklist TYPE OF DENTIST: In order to expedite the credentialing process, please complete every item on this application. Please, DO NOT write, See CV or

More information

Provider Information Change Form I. PERSONAL INFORMATION

Provider Information Change Form I. PERSONAL INFORMATION Internal #: For Internal Use Only (Individual Application) Reason: New Provider Provider Information Change Form I. PERSONAL INFORMATION Name:.. First Middle Last Suffix Degree (MD,RN, etc.) Gender: M

More information

Hospital/Facility Provider Application

Hospital/Facility Provider Application Hospital/Facility Provider Application Instructions: In order for the application to be considered complete: 1. All information must be legible. Please print or type all information. 2. A separate application

More information

Application for Medical Staff Appointment and Clinical Privileges. Part I. Credential Review

Application for Medical Staff Appointment and Clinical Privileges. Part I. Credential Review Application for Medical Staff Appointment and Clinical Privileges Part I. Credential Review I am applying for clinical privileges at the location(s) checked below: 6209 16 th Avenue, Brooklyn, NY 11214

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

Policy No.: CR006_07. Title: Delegated Credentialing and Recredentialing Policy QM CR 04 02, CR 07 08

Policy No.: CR006_07. Title: Delegated Credentialing and Recredentialing Policy QM CR 04 02, CR 07 08 Title: Delegated Credentialing and Recredentialing Policy Previous Title (if applicable): Department Applicability: Credentialing Lines of Business: Medi Cal, Healthy Families, Healthy Kids, Agnews Originating

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

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

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION INSTRUCTIONS: In order to be considered complete: 1. All information must be legible. Please print or type all information 2. Application must

More information

2014 NURSE PRACTITIONER RESIDENCY

2014 NURSE PRACTITIONER RESIDENCY 2014 NURSE PRACTITIONER RESIDENCY Glide Health Services in partnership with UCSF School of Nursing and Community Health Center, Inc. APPLICATION INSTRUCTIONS Thank you for your interest in the Nurse Practitioner

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

Provider Selection Criteria for PreferredOne Participating Physicians

Provider Selection Criteria for PreferredOne Participating Physicians Provider Selection Criteria for PreferredOne Participating Physicians General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne product for which they

More information

THE UNIVERSITY OF MISSISSIPPI MEDICAL CENTER

THE UNIVERSITY OF MISSISSIPPI MEDICAL CENTER INSTRUCTIONS FOR NEW APPLICATIONS AND REAPPOINTMENT APPLICATIONS FOR CLINICAL PRIVILEGES AT THE UNIVERSITY OF MISSISSIPPI MEDICAL CENTER Applicant: Department: Please return this form with your application

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

Now Accepting Applications for Nurse Practitioner Residency Full-Time 10 Month Appointment Starts January 9, 2012

Now Accepting Applications for Nurse Practitioner Residency Full-Time 10 Month Appointment Starts January 9, 2012 Now Accepting Applications for Nurse Practitioner Residency Full-Time 10 Month Appointment Starts January 9, 2012 The University of California Los Angeles School of Nursing Health Center at the Union Rescue

More information

CREDENTIALING PLAN SECTION ONE INDIVIDUAL PROVIDERS

CREDENTIALING PLAN SECTION ONE INDIVIDUAL PROVIDERS CREDENTIALING PLAN SECTION ONE INDIVIDUAL PROVIDERS I. STATEMENT OF POLICY A. The purpose of Avera Credentialing Verification Service (CVS) is to provide credentialing and recredentialing primary source

More information

DUE DATE: Please note: There will be a $175 late fee assessed for any packets that are received incomplete or not returned prior to this date.

DUE DATE: Please note: There will be a $175 late fee assessed for any packets that are received incomplete or not returned prior to this date. Dear Medical/Adjunct Staff Member: It is time for your biannual reappointment to the Medical Staff/Adjunct Staff of The University Hospital. Attached, you will find your application and delineation of

More information

HMSA BEHAVIORAL HEALTH FACILITY/PROGRAM CREDENTIALING DOCUMENT CHECKLIST

HMSA BEHAVIORAL HEALTH FACILITY/PROGRAM CREDENTIALING DOCUMENT CHECKLIST 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.

More information

Email (the majority of EAP Administrator use email to refer cases)

Email (the majority of EAP Administrator use email to refer cases) NASW Assurance Services, Inc. EAPrefer - Employee Assistance Program (EAP) Network Application - (Type or legibly print application in ink) Member Information NASW Member ID# Date of Birth (optional) Gender

More information

Washington Practitioner Application

Washington Practitioner Application Washington Practitioner Application To use the Washington Practitioner Application (WPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When

More information

Name: Last First Middle Other Names Used

Name: Last First Middle Other Names Used Name(s) of Health Care Organization(s) to Which Application is Being Made Date of Application: Name: Last First Middle Other Names Used Circle all that apply and for which you are currently licensed: MD

More information

Washington Practitioner Application

Washington Practitioner Application Washington Practitioner Application To use the Washington Practitioner Application (WPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When

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

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

Credentials Policy Manual. Reviewed & Approved by MEC 8/13/2012 Reviewed & Approved by Board of Commissioners 9/11/12

Credentials Policy Manual. Reviewed & Approved by MEC 8/13/2012 Reviewed & Approved by Board of Commissioners 9/11/12 Credentials Policy Manual Reviewed & Approved by MEC 8/13/2012 Reviewed & Approved by Board of Commissioners 9/11/12 Credentialing Policy Manual Table of Contents I. Application for Appointment to Staff...1

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

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

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

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

PLATTE COUNTY MEMORIAL HOSPITAL MEDICAL STAFF CREDENTIALING POLICY ARTICLE I DEFINITIONS

PLATTE COUNTY MEMORIAL HOSPITAL MEDICAL STAFF CREDENTIALING POLICY ARTICLE I DEFINITIONS PLATTE COUNTY MEMORIAL HOSPITAL MEDICAL STAFF CREDENTIALING POLICY ARTICLE I DEFINITIONS The following definitions shall apply to terms used in this policy: (1) "Board" means the Board of Directors of

More information

Please read the information below to assist you in submitting the on-line application and the supplemental forms.

Please read the information below to assist you in submitting the on-line application and the supplemental forms. DMC Corporate Medical Affairs/CVO 4707 St. Antoine, Ste. E510/Hutzel Building Mail Code 522 Detroit, Michigan 48201-1498 313-993-0203 Phone 313-993-0010 Fax Dear Applicant: Thank you for your interest

More information

Florida Credentialing Application Checklist

Florida Credentialing Application Checklist APPLICANT NAME: Florida Credentialing Application Checklist TYPE OF DENTIST: In order to expedite the credentialing process, please complete every item on this application. Please, DO NOT write, See CV

More information

Practitioner Profile General Information License Number:

Practitioner Profile General Information License Number: Practitioner Profile General Information Primary Practice Address: (456.039 (1) (a) 3., F.S.) Medicaid: (456.039 (1) (b) (5) d., F.S.) Select Medicaid Statement: This practitioner does participate in the

More information

Nonphysician Practitioner Policy a.k.a. Specified Professional Personnel Policy

Nonphysician Practitioner Policy a.k.a. Specified Professional Personnel Policy RENOWN REGIONAL MEDICAL CENTER Nonphysician Practitioner Policy a.k.a. Specified Professional Personnel Policy (The Term Allied Health Professional will not be used in this policy since in the Renown Regional

More information

GEORGIA UNIFORM HEALTHCARE PRACTITIONER CREDENTIALING APPLICATION FORM

GEORGIA UNIFORM HEALTHCARE PRACTITIONER CREDENTIALING APPLICATION FORM GEORGIA UNIFORM HEALTHCARE PRACTITIONER CREDENTIALING APPLICATION FORM Please contact the Hospital, Health Plan or other Healthcare Organization, hereinafter "Healthcare Entity(ies)", to which you are

More information

6325 Hospital Parkway Johns Creek, Georgia 30097 Phone 678-474-7000 emoryjohnscreek.com

6325 Hospital Parkway Johns Creek, Georgia 30097 Phone 678-474-7000 emoryjohnscreek.com Dear Provider, Thank you for your recent inquiry in credentialing at Emory Johns Creek Hospital. Through our affiliation with Emory Healthcare, we are pleased to announce that our application process is

More information

RADIOLOGY CREDENTIALING APPLICATION

RADIOLOGY CREDENTIALING APPLICATION RADIOLOGY CREDENTIALING APPLICATION CREDENTIALING CHECKLIST FACILITY INFORMATION Facility application completed in its entirety and signed/dated by Authorized signatory Copy of all current facility licenses/certifications

More information

MASSAGE THERAPY CERTIFICATE 2016 LICENSE APPLICATION INSTRUCTIONS City of Plymouth 3400 Plymouth Boulevard, Plymouth, MN 55447 763-509-5000

MASSAGE THERAPY CERTIFICATE 2016 LICENSE APPLICATION INSTRUCTIONS City of Plymouth 3400 Plymouth Boulevard, Plymouth, MN 55447 763-509-5000 MASSAGE THERAPY CERTIFICATE 2016 LICENSE APPLICATION INSTRUCTIONS City of Plymouth 3400 Plymouth Boulevard, Plymouth, MN 55447 763-509-5000 The following application forms must be completed, by the individual

More information

OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST

OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST APPLICATION INSTRUCTIONS AND INFORMATION General Statement:

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

CREDENTIALING POLICY AND PROCEDURES MANUAL OF THE MEDICAL STAFF OF ADVENTIST HINSDALE HOSPITAL AND ADVENTIST LA GRANGE MEMORIAL HOSPITAL

CREDENTIALING POLICY AND PROCEDURES MANUAL OF THE MEDICAL STAFF OF ADVENTIST HINSDALE HOSPITAL AND ADVENTIST LA GRANGE MEMORIAL HOSPITAL CREDENTIALING POLICY AND PROCEDURES MANUAL OF THE MEDICAL STAFF OF ADVENTIST HINSDALE HOSPITAL AND ADVENTIST LA GRANGE MEMORIAL HOSPITAL Approval: Medical Executive Committees: Hinsdale Hospital July 28,

More information

Appendix B-1 Acceptance/continued participation criteria Primary care nurse practitioner

Appendix B-1 Acceptance/continued participation criteria Primary care nurse practitioner Appendix B-1 Acceptance/continued participation criteria Primary care nurse practitioner Amendments to this Appendix B-1 shall be effective as of August 1, 2012 (the Amendment Date ). To be initially admitted

More information

Provider Selection Criteria for PreferredOne Participating Certified Registered Nurse Anesthetists

Provider Selection Criteria for PreferredOne Participating Certified Registered Nurse Anesthetists Provider Selection Criteria for PreferredOne Participating Certified Registered Nurse Anesthetists General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne

More information