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 application. Provide the CAQH ID number instead of completing Neighborhood s application and include any attachment noted below as applicable that cannot be obtained with the online CAQH application. CAQH ID # In addition to Neighborhood standard credentialing application, the following documents (if applicable) are needed in order to meet our credentialing requirements. Please attach them to your completed credentialing application. Attachments: Board Certification Certificate CLIA Certificate Current copy of your federal DEA registration certificate for each state of practice Copy of Controlled Substance Registration Certificate (CDS) Copy of Current License Current Curriculum Vitae (CV) Documenting Work History for the last 5 years ECFMG Certificate controlled dangerous substance certificate (if applicable) Current copy of malpractice insurance face sheet Physician Assistant Questionnaire (attached) Name of Physician Assistant s supervising physician Description of Physician Assistant s responsibility at the site, written by the supervising physician Ownership Disclosure Form (completed, signed & dated) Regulatory Compliance Monitoring Certification Form (signed & dated) Contract and/or Addendum (signed & dated) W-9 In order for the application to be processed, practitioners must be currently licensed in the state where they plan to see Neighborhood Health Plan of RI patients (Rhode Island and/or Massachusetts); provide the social security number and date of birth. Thank you for your cooperation. Practitioners have the right to: Review information submitted to support the credentialing application and correct erroneous information by submitting a written request to credentialing Department. Be informed of the status of their credentialing application upon request by calling credentialing department at 401-459-6000. Revised October 2012 Page 1 S:\Common\Credentialing\Credentialing Application\Initial Credentialing Application 9.2014

PRACTITIONER INFORMATION Provider Name: Last First Middle Initial Residence : Street Zip Email : Gender: Male Female DOB: / / SSN: / / Place of Birth: Maiden/Other Names Used During Professional Career: Ethnicity: White American Indian/Native American Black/African American Hispanic/Latino Asian Native Hawaiian / Other pacific Islander Other (This information is being captured to ensure that the ethnic/cultural preferences of our members align with the NHPRI provider network availability). This application is for participation as a (Check all that apply): MD; DO; DPM; DC; DA; OD; CNM; CRNA; ST; PT; OT; MT; NP*; PA**; ; Other: Applying as a (check one): Primary Care Practitioner members assigned Specialist Both no members assigned Accepting New Patients? Yes No *For NP s applying as PCP s with members assigned, indicate the name of a collaborating NHPRI contracted primary care practitioner: ** PA must be working under supervision of a physician contracted with Neighborhood: Name of supervising physician (s) SPECIALTY BOARD CERTIFICATION Primary Specialty: Percentage of Practice: % Board Certified: YES NO Year Certified: Expiration *Board Eligible: YES NO Effective Expiration Examination Take: YES NO Date Taken: / / Oral Written Secondary Specialty: Percentage of Practice: % Board Certified: YES NO Year Certified: Expiration *Board Eligible: YES NO Effective Expiration Examination Take: YES NO Date Taken: / / Oral Written *NOTE: Satisfactorily completed an accredited residency or fellowship program and is planning to become Board Certified within a specified period. Other specialty: Percentage of Practice: % ABMS Certificate Of Special Or Added Qualifications: PROFESSIONAL LICENSURE/REGISTRATIONS List all licenses held in the past 5 years & specialty type, e.g. MD,DO,DPM, etc. Indicate license restrictions if any. /Country Type Number Year Issued Expiration Date Restrictions / / / / / / Medicare Provider Number(s): Medicare (N) UPIN: Medicaid Provider Number(s): ECFMG Number: DEA Number (s) NPI number : Page 2

PRACTICE INFORMATION Primary Office : Group Name Office Manager ( ) - Phone Number Suite ( ) - Fax Number Credentialing Contact (Name & Phone Number) Tax ID Number E-Mail List in Directory: YES NO Handicap Accessible: YES NO Start Date W/Group (MM/YY): / Applicant s Appointment Availability (From To): MON. TUES. WED. THURS. FRI. SAT. SUN. (Primary Care Sites must be open for 30 hrs of appointment time. Each Primary Care Practitioner must have 17.5 hrs of appointment time.) Primary Billing (if more than one billing address, please attach separate sheet): Check Payable To Contact Name ( ) - Phone Number ( ) - Fax Number Group NPI Number Secondary Office : Group Name Office Manager ( ) - Phone Number Suite ( ) - Fax Number Credentialing Contact (Name & Phone Number) Tax ID Number E-Mail List in Directory: YES NO Handicap Accessible: YES NO Start Date W/Group (MM/YY): / Applicant s Appointment Availability (From To): MON. TUES. WED. THURS. FRI. SAT. SUN. (Primary Care Sites must be open for 30 hrs of appointment time. Each Primary Care Practitioner must have 17.5 hrs of appointment time.) Secondary Billing (if different than above): Check Payable To Contact Name ( ) - Phone Number ( ) - Fax Number Group NPI Number Applicant Name: Page 3

PRACTICE INFORMATION (CONTINUED) Do you currently belong to any other HMO? If yes, please list: Do you speak any foreign languages/sign language? If yes, please list: Do you have TDD (hearing impaired) equipment? Do you have other services for the disabled? If yes, please list: Which age groups do you treat? All ages 0-13 yrs. 14-18 yrs. 19-65 yrs. 65+ yrs. Do you limit your practice on any other basis such as your subspecialty? If yes, please indicate the limitation: Do you perform any laboratory tests in your office? If yes, please provide a copy of the CLIA Certificate and list testing: Please check which of the following diagnostic and therapeutic modalities/facilities are present in your office and list any additional procedures and any special diagnostic testing (e.g. surgical procedures, etc.) you perform in your office, including any equipment used. X-ray Phlebotomy Diagnostic ultrasound Endoscopy Routine EKG Other: Office-based surgical suite Procedures include: _ What is the average waiting time to obtain an office appointment for: Initial Visit: Urgent Visits: _ Average number of patients seen each day: Follow-up Visits: Annual Exam: Are you available or do you have coverage 24 hours a day, seven days a week? COVERAGE OF PRACTICE: Please describe after-hours arrangements for your patients: If answering service or machine is used, please list available languages: Applicant Name: Page 4

PARTNERS/ASSOCIATES AND COVERING PROVIDERS Please list all other current partners/associates in your practice and providers who cover for you, with their respective specialties. NAME SPECIALTY PHONE # PARTNER COVERING CONTRACTED W/ PLAN Do you employ any clinical professionals (e.g. Nurse Practitioners, PTs, OTs, STs, or CNMs)? Yes No Will these clinicians also contract with the Health plan? Yes No WORK HISTORY Please list previous employers for the last 5 years and/or attach an up to date Curriculum Vitae with at least the past five (5) years of work history: Group/Practice Name, From To (Month/Year) / - / / - / / - / / - / / - / / - / Please explain all gaps that exceed six (6) months within your work history: ACADEMIC APPOINTMENTS Please indicate any teaching appointments you currently hold. Institution Name: Title: : Institution Name: Title: : From: / To: / From: / To: / Applicant Name: Page 5

MEDICAL/PROFESSIONAL EDUCATION Institution Name Degree Awarded: Dates Attended: / - / or Country Graduation Date: / INTERNSHIP/RESIDENCY/FELLOWSHIP Institution Name or Country Internship Residency Fellowship Dates Attended: / - / Program Director Current Program Director (If different & Known) Institution Name or Country Program Director Current Program Director (If different & Known) Institution Name or Country Name of Program Completed: YES NO Internship Residency Fellowship Dates Attended: / - / Name of Program Completed: YES NO Internship Residency Fellowship Dates Attended: / - / Program Director Current Program Director (If different & Known) Name of Program Completed: YES NO Applicant Name: Page 6

HOSPITAL & HEALTH CARE AFFLIATIONS List all current and previous hospital affiliations and appointment dates for the LAST FIVE YEARS. Name of Primary Hospital: Approx. # of admissions in the past 12 months Do you have unrestricted admitting privileges at the above facility? YES NO Name Of Hospital Name Of Hospital Name Of Hospital Department/Service Department/Service Department/Service Staff Status: Active Courtesy Other Admitting Privileges: YES NO Staff Status: Dates From To: / - / Active Courtesy Other Admitting Privileges: YES NO Staff Status: Dates From To: / - / Active Courtesy Other Admitting Privileges: YES NO Dates From To: / - / If you do not admit patients or have restricted hospital admitting privileges, what type of arrangements do you have for hospital and inpatient coverage for your patients? Please provide a detailed description including all provider names as well as a copy of the signed agreement between you and the NHPRI credentialed practitioner or hospitalists, who will be admitting and providing inpatient coverage. MALPRACTICE/INSURANCE CARRIER Please attach a copy of your current Malpractice Insurance Face Sheet. CURRENT INSURANCE CARRIER _ YEARS WITH CURRENT CARRIER ADDRESS CITY STATE ZIP CODE POLICY NUMBER _ AMOUNT OF COVERAGE Have you ever had any professional liability insurance coverage cancelled denied or modified (e.g. reduced limits, restricted coverage), has any renewal ever been refused, have you voluntarily given up coverage or have you had an individual surcharge placed on you based on your individual experience? Yes No If yes, please explain: Applicant Name: Page 7

PROFESSIONAL QUESTIONNAIRE Questions 1 thru 16 pertain to the LAST TEN YEARS. If you answer YES to any of the questions below, you must submit an explanation as part of this application. 1. Has your professional license to practice in any jurisdiction ever been restricted, suspended, revoked, surrendered, with-drawn or have you been reprimanded, admonished or censured by any licensing board? 2. Have you ever been denied a professional license whether full, limited or temporary? 3. Has your ability to prescribe controlled substances been voluntarily or involuntarily restricted, suspended or revoked in any jurisdiction? 4. Has your Federal DEA Number ever been suspended or revoked? 5. Have your hospital privileges or membership on the staff of any institution been voluntarily or involuntarily suspended, diminished, altered, revoked, not renewed, withdrawn or have you been subject to a disciplinary action completed or ongoing? 6. Have any formal or written complaints against you been filed with the Professional Licensure Board in your state or any other state? 7. Have you been denied initial (or renewal of) membership, or been subject to disciplinary proceedings, in any health care organizations? 8. Have you ever been sanctioned by a PRO or any federal or state agency? 9. Have you withdrawn an application for medical licensure, hospital privileges or appointment for any reason? 10. Has any Federal or agency ever taken any action which limited your ability to participate in Medicare or Medicaid? 11. Have you ever been required or agreed to pay civil monetary penalties under Medicare or Medicaid or otherwise sanctioned by HCFA? 12. Do you have any felony or misdemeanor charges pending or have you ever been convicted of charges other than a minor traffic violation? 13. Is your physical or mental health such that it may impair your ability to practice within the scope of privileges for which you have applied with or without reasonable accommodation? 14. Does your use of alcohol or other chemical substance(s) in any way impair or limit your ability to practice medicine with reasonable skill and safety? 15. Are you currently using illegal drugs or controlled substances? 16. Are you currently participating in a supervised rehabilitation program or professional assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled substances? 17. Have any formal or written claims alleging malpractice been opened, pending or resolved against you in the last five years? (If yes, a complete explanation on Page 9 of this application must be provided). Applicant Signature (Stamped signatures cannot be accepted) / / Date Signature must be no more than 180 days old at the time of credentialing committee meeting. This page must be resigned if expired. Page 8

PROFESSIONAL LIABILITY EXPERIENCE/HISTORY Number of claim suits submitted with this application: Carrier at Time of Incident: Date of Alleged Incident: / / Name of Court and Case Number: Date of Lawsuit Filed: / / Date of Settlement: / / Please provide a summary adequate to describe the clinical significance of the claim: Status of Case (with reference to you specifically): What was/is your status: Notice of Claim Filed Sole Defendant Pending Before Malpractice Panel Co-Defendant with: Pending in Court Closed Without Payment Other: Pre-Trial Settlement: ($ ) Verdict for Defendant Verdict for Plaintiff: ($ ) Number of claim suits submitted with this application: Carrier at Time of Incident: Date of Alleged Incident: / / Name of Court and Case Number: Date of Lawsuit Filed: / / Date of Settlement: / / Please provide a summary adequate to describe the clinical significance of the claim: Status of Case (with reference to you specifically): What was/is your status: Notice of Claim Filed Sole Defendant Pending Before Malpractice Panel Co-Defendant with: Pending in Court Closed Without Payment Other: Pre-Trial Settlement: ($ ) Verdict for Defendant Verdict for Plaintiff: ($ ) **PLEASE COPY THIS PAGE FOR EACH ADDITIONAL CLAIM SUIT AND ATTACH TO APPLICATION** Applicant Name: Page 9

CERTIFICATION, AUTHORIZATION AND RELEASE OF INFORMATION In submitting this application for credentialing (or recredentialing) I understand that it is my responsibility to produce the required information and that the attached documents contain detailed and specific information relating to my character and professional competence. I hereby certify under pains and penalties of perjury that the information contained herein, including all supporting materials, is true and complete to the best of my knowledge and belief. I understand that my application will be reviewed based upon the information I have provided and other information obtained by the Health Plan in accordance with its credentialing program. I further understand that information which is found to be false could result in a denial or termination of the Health Plan s credentials and participation status. I authorize the Health Plan to consult with any person or entity who has information bearing on my competence, character and ethical qualifications and to inspect such records which may be material to the evaluation of my professional qualifications and competence. I authorize all professional licensing agencies in any state in which I am licensed to practice, and any health care organization or professional organization with whom I have had employment, practice, association or privileges, to release information to the Health Plan regarding my professional skills, any pending or final disciplinary action or malpractice action, and any other information relevant to my character or professional competence and/or ability to perform. I authorize and request my malpractice liability insurance carrier to release information regarding any claims or actions for damages pending or closed during the previous ten years, whether or not there has been a final disposition. I understand that this application does not entitle me to participation in the network of any Health Plan using this application. I agree that any Health Plan using this application, their representatives, and any individuals or entities providing information to such health plans in good faith shall not be liable for any act or omission related to the evaluation or verification contained in this application. I agree to notify the Health Plan with which I participate and which use this application about any change to the information provided in this application within 30 days of any such change. I fully understand that this authorization and release extends for a period of three years which covers the length of time between my current credentialing and my next credentialing with the health plan. I understand that a report may be submitted to the appropriate state licensing board and/or the National Practitioner Data Bank in the event that the application is rejected for reasons pertaining to professional conduct or competence. I understand that a site visit and medical record review may be performed by the Health Plan prior to participation in the Health Plan. I authorize the Health Plan to provide my credentialing status to the leadership of all Provider Unit and Hospital Credentialing Offices which I am affiliated. I recognize that the credentialing process is continuous and ongoing, that the Health Plan will credential and continuously recredential me, and that the authorizations, acknowledgements, consents and releases provided in this application will remain in effect for purposes of the processes of ongoing credentialing and recredentialing until revoked by me in writing. Information requested in this application that is not publicly available will be treated as confidential by the Health Plan using it. My signature here authorizes verification of the information I have provided. Applicant Signature (Stamped signatures cannot be accepted) / / Date Printed Name Signature must be no more than 180 days old at the time of credentialing committee meeting. Attestation must be resigned if expired. Page 10