Participating Provider/Non-owner member Are you currently a PAID board member or consultant for any other vision plan? YES NO Date:, 20 Please make check out to Opt Net and mail your $100 provider credentialing fee to: Kelly Haight 28120 US Hwy., 281 North, Suite 108 San Antonio, TX 78260 I understand that the IPA is owned and operated by the doctors of the state. All doctors share equally in marketing expense. Each doctor may be assessed a monthly marketing reserve. Provider Signature: Through Vision Care Direct, provider offices can offer an individual vision plan to their patients and receive a 5% Referral Fee as long as that patient remains on Vision Care Direct. If the patient enrolls via our on-line enrollment system, they can receive a 10% discount off the internet rates simply by entering a promo code assigned to your office. We ask for your assistance in naming this promo code. Think of a word, numbers or combination thereof you would like to use (i.e. FAMILY VISION, VISION123, DRSMITH) and enter it below. DESIRED PROMO CODE: DO YOU HAVE A WEBSITE? WHAT IS THE ADDRESS? Provider Signature: Please attach a copy of IRS form W-9 with your application; if referral fee is to be paid to the Practice, complete with the name of the practice. You can find a copy at: http://www.irs.gov/pub/irs-pdf/fw9.pdf
To be considered for panel participation, please submit this application and the completed Provider Agreement Eyetopia within 15 days of date received: Please submit by fax to (801) 607-7468 or by email to JoinIPA@visioncaredirect.com. LAST NAME FIRST NAME M.I. O.D. M.D. D.O. UPIN SOCIAL SECURITY NUMBER KNOWN BY OTHER NAME MALE FEMALE PRIMARY OFFICE MAILING ADDRESS STREET ADDRESS CITY STATE ZIP TELEPHONE NUMBER YOUR EMAIL ADDRESS FAX NUMBER EMERGENCY NUMBER LICENSING STATE LICENSE(S) LICENSE NUMBER STATE EXPIRATION DATE LICENSE NUMBER STATE EXPIRATION DATE LICENSE NUMBER STATE EXPIRATION DATE DO YOU HAVE A FEDERAL CONTROLLED SUBSTANCES (DEA) LICENSE? YES NO ARE THERE ANY RESTRICTIONS ON YOUR FEDERAL CONTROLLED SUBSTANCES (DEA) LICENSE? YES NO STATE AND NATIONAL PROFESSIONAL AFFILIATIONS TOA? YES NO AOA? YES NO ADDITIONAL PROFESSIONAL AFFILIATIONS ADDITIONAL PROFESSIONAL AFFILIATIONS ADDITIONAL PROFESSIONAL AFFILIATIONS
PROFESSIONAL QUESTIONS DOCTOR NAME If you answer YES to any of the questions below, please attach detailed information regarding the situation. 1. Has your license or registration to practice (optometry/medicine) in any jurisdiction or your narcotics registration (DEA, CDS) ever been sanctioned, voluntarily or involuntarily revoked, placed on probation, fined/penalized, suspended or limited in any manner, including directives, or is any such action pending? Yes No 2. Has your Medicare and/or Medicaid participation ever been revoked, suspended, restricted or limited in any manner, or any such action or investigation pending? Yes No 3. Has your Professional Liability or General Liability Insurance ever been denied, canceled or refused renewal? Yes No 4. Has there ever been voluntary or involuntary termination of medical staff membership or voluntary or involuntary limitation, reduction, disciplinary activity or loss of clinical privileges at any health care organization, or is any such involuntary action pending? Yes No 5. Have you ever resigned a health care organization membership to avoid disciplinary action, or is any such action pending? Yes No 6. Have you ever been subject to disciplinary action in any health care organization, or is any such action pending? Yes No 7. Have you ever been convicted of a felony or misdemeanor, or is any such action pending? Yes No 8. Are you now or have you ever been involved in a malpractice suit, including arbitration, or has any malpractice claim or settlement, not involving litigation or arbitration, ever been paid by you or paid on you behalf? Yes No 9. Do you currently engage in illegal drug use? Yes No 10. Is there any reason you are not able to perform all the requirements outlined by New Mexico State Law and Regulations, with or without reasonable accommodation, according to accepted standards of professional performance and without posing a direct threat to patients? Yes No 11. Are you a current member of VSP at each location? Yes No 12. Is each office where patients are seen HIPAA compliant? Yes No LIST OTHER PROVIDER PANELS YOU ARE CURRENTLY ON AS AN ACTIVE PROVIDER 1. 2. 3. 4. 5. 6. 7. 8.
PRACTICE/CLINIC NAME MAIN PRACTICE NAME PHYSICAL OFFICE STREET ADDRESS CITY COUNTY STATE ZIP OFFICE PHONE FAX NUMBER EMERGENCY NUMBER NUMBER OF ADDITIONAL OFFICES: (PLEASE COMPLETE AN ADDITIONAL OFFICE LOCATION FORM FOR EACH OFFICE.) NPI # TAX ID # EQUIPMENT Each office where care is provided must have the below listed equipment in good working order on site to perform patient examinations and for Quality Management Provider Review. Biomicroscope (Slit Lamp) Blood Pressure Measuring Device Contact Lens Magnifier with Reticule Contact Lens Thickness Gauge for Rigid Lens (or lens clock) Lensometer Ophthalmoscope Phoropter Radiuscope and/or Keratometer Attachment Tonometer Visual Field Screening Device Binocular Indirect Ophthalmoscope and Condensing Lens Foreign Body Removal Instruments Gonioprism Irrigators Lacrimal Dilators Punctal Plugs Threshold Visual Fields Device Volk or Hruby Type Lens I declare that I have the above equipment in my office(s) during all patient care. I agree to comply with any updates to the equipment requirements as identified in further notifications. In addition, I agree to have the required equipment onsite at my office(s) at the time of a Quality Management Provider Review. Name: Signature Date
SERVICES At each office, do you have 51% or more ownership of the dispensing portion of the practice? If no, who owns the dispensary at each location? Yes No Does each office have at least 500 frames on display at all times for patients? Yes No Does each office stock at least five safety frame models which fall within the $25 frame allowance, with safety shields? At least one model includes permanent side shields and falls within the $25 frame allowance? Yes No Are contact lenses dispensed at each office? Yes No OTHER VISION CARE DOCTORS WHO PRACTICE AT THIS LOCATION (FULL OR PART TIME) NAME STATE LICENSE # HOURS/WEEK ASSOCIATE EMPLOYEE OWNER NAME STATE LICENSE # HOURS/WEEK ASSOCIATE EMPLOYEE OWNER NAME STATE LICENSE # HOURS/WEEK ASSOCIATE EMPLOYEE OWNER NAME STATE LICENSE # HOURS/WEEK ASSOCIATE EMPLOYEE OWNER NAME STATE LICENSE # HOURS/WEEK ASSOCIATE EMPLOYEE OWNER NAME STATE LICENSE # HOURS/WEEK ASSOCIATE EMPLOYEE OWNER NAME STATE LICENSE # HOURS/WEEK ASSOCIATE EMPLOYEE OWNER NAME STATE LICENSE # HOURS/WEEK ASSOCIATE EMPLOYEE OWNER Name: Signature Date
HOURS OFFICE IS OPEN FOR BUSINESS Texas Eyetopia LOCATION LIST THE BUSINESS HOURS THIS OFFICE IS OPEN MON TUES WED THURS FRI SAT SUN OPEN CLOSED Does this office provide emergency service to patients during regular business hours? (walk-ins, triaging, immediate service?) Yes No Does this office have an after hours emergency call system? Yes No DOCTOR NAME LIST THE HOURS EACH DOCTOR ROUTINELY WORKS IN THIS OFFICE MON TUES WED THURS FRI SAT SUN IN OUT DOCTOR NAME LIST THE HOURS EACH DOCTOR ROUTINELY WORKS IN THIS OFFICE MON TUES WED THURS FRI SAT SUN IN OUT DOCTOR NAME LIST THE HOURS EACH DOCTOR ROUTINELY WORKS IN THIS OFFICE MON TUES WED THURS FRI SAT SUN IN OUT USE ADDITIONAL PAGES IF NECESSARY
CONDITIONS OF APPLICATION By applying for membership to the Eyetopia and Vision Care Direct I hereby; signify my willingness to appear for interviews in regard to my application; authorize the staff and appropriate representatives to consult with my previous and current associates and others who may have information bearing on my professional competence, character, health status, ethical qualifications, ability to work cooperatively, and other qualifications; consent to the inspection by the staff, its Medical or Optometric Director, and their representatives of all documents that may be material to an evaluation of my qualifications and competence; consent to release from any liability, to the fullest extent permitted by law, Eyetopia and Vision Care Direct its staff, and all its employees, agents, and representatives, for acts performed in connection with evaluating me, including recommendations made in connection with this application; consent to release from liability anyone who provides information to Eyetopia and Vision Care Direct, in good faith and without malice concerning my professional competence, ethics, character, and other qualifications for membership; pledge to maintain the ethical practice, to provide for continuous care for my patients, and to refrain from delegating the responsibility for any aspect of the care of my patients to any practitioner not qualified to undertake that responsibility; agree to keep Eyetopia and its representatives up to date on any change made or proposed in the status of my professional license to practice, DEA or other controlled substances registration, professional liability insurance coverage, status of claims, initiation of new malpractice claims and appointment or clinical privileges at other institutions; acknowledge that I, as an applicant have the responsibility of producing adequate information for proper evaluation of my professional, ethical, and other qualifications for appointment and for resolving any doubts about such qualifications; and acknowledge that any misstatements or omissions in this application constitute cause for denial of appointment or cause for summary dismissal. All information, including supporting documentation, submitted by me in connection with this application is true and complete to the best of my knowledge and belief. I agree to update this application while it is being processed, should there be any changes in the information provided that could affect the application or its outcome. Original Signature of Applicant (no stamps) Date Signed Printed Name and Title of Applicant
EXAMS Item Eligibility: Please visit www.vcdplans.com for member s plan and eligibility details Reimbursement Eye Exam, New Patient, Comprehensive $89.00 Eye Exam, Established Patient, Comprehensive $89.00 * Any office visits pertaining to 'medical' eye problems must be billed to the member s major medical plan or member pays directly 'out-of-pocket'. * Amounts listed in this table are the total providers are reimbursed the sum of both what the plan pays and the member's exam co-pay (typically $15.00) FRAMES Item Reimbursement 100 Plan Reimbursement 130 Plan Reimbursement 160 Plan Frames $45.00 $75.00 $105.00 * Member eligible for $100, $130 or $160 retail allowance towards any frame. Member is responsible for overage above retail allowance. * The difference between the plan reimbursement (see chart above) and the allowance is a write off (Allowance $100 minus VCD reimbursement $45 = write off $55). The member is responsible for the amount above plan allowance and retail frame cost. LENSES Item Single Vision - All sphere or spherocylinder, glass or plastic (CR-39). * No extra charge on over size. Bifocal - All sphere or spherocylinder, glass or plastic (CR-39), bifocal, FT 25 or FT 28. * Member is responsible for overage on seg widths >28mm or on any specialty bifocals. * No extra charge on oversize. Trifocal - All sphere or spherocylinder, glass or plastic (CR-39), trifocal, 7x25 or 7x28. * Member is responsible for overage on seg widths >28mm or on any specialty trifocals. * No extra charge on oversize. * Example: Your regular fee (UCR) for a 7x28 trifocal is $120 and your (UCR) for a progressive lens is $190, therefore, the member pays the difference of $70 Progressive (Platinum plans) - All sphere or spherocylinder, glass or plastic (CR-39), progressive add. * Our Platinum plans give the member a $180 allowance specifically for progressive lenses. Member is responsible for overage above retail allowance. The difference between wholesale cost & retail allowance is a write-off, do not bill the member. Progressive (all other plans) - All sphere or spherocylinder, glass or plastic (CR-39), progressive add. * Member pays the difference between your UCR of a 7x28 trifocal and your UCR of a Progressive lens. Reimbursement $65.00 $95.00 $115.00 $140.00 $115.00 * All lens upgrades or add-ons (hi-index, tints, hard-coat, AR coating, UV, etc.) are charged at full retail prices. (Member pays you your UCR). * Amounts listed in this table are the total reimbursed the sum of both what the plan pays and the member's materials co-pay (typically $15.00) EXAMPLE 100 Plan, Single vision lenses with AR and $180 frame Product Doctor UCR VCD Member Reimbursement Responsibility Total Revenue Frame $180 $45 $80 $125 Lens $75 $50 $15 $65 A/R $90 $0 $90 $90
SUNWEAR TINT Item Solid or Gradient Tint Plastic lenses only solution dye * Only available on Prescription Sunwear Plan Reimbursement $10.00 STUDENT PLAN (K-12) Item Polycarbonate Lenses * Polycarbonate lenses are Standard of Care. PC lenses required on all student Rx s. Reimbursement $30.00 CONTACT LENSES Item Reimbursement 100 Plan Reimbursement 130 Plan Reimbursement 160 Plan Contact Lenses $105.00 $130.00 $160.00 * Elective Contact lenses paid at full retail prices. (Member pays the difference between allowance of $105, $130, or $160 and your UCR). * Medically necessary lenses allowance - $250 (aphakia, keratoconus only). (Member pays the difference between allowance of $250 and your UCR). IPA medical board must approve prior to submitting a claim. Your office must submit medical records including corneal map. PRE & POST-OP LASER REFRACTIVE SURGERY CARE Please visit www.vcdplans.com for details on refractive surgery benefits. OTHER IMPORTANT NOTES Use the laboratory of choice including your own, however, we highly recommend using one of our preferred vendor laboratories. Contact your IPA executives for more information. Eligibility determined easily and quickly. Visit www.vcdplans.com.