participating provider credentialing application physicians and other

Transcription

PARTICIPATING PROVIDER CREDENTIALING APPLICATION
PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS
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
License
State Membership (Colegiación)
DEA
Number:_______________
Number:__________________
Exp.
Date:_________________
(mm/dd/yy)
Social Security Number:
Exp. Date:_________________
(mm/dd/yy)
MI
Date of Birth (MM/DD/YY)
ASSMCA (Licencia Narcóticos Estatal)
(Licencia Narcóticos Federal)
YES:
Number:______________
YES:
Expiration Number:______________
Number:______________
Expiration Number:______________
NO
NO
Medicare #:
CLIA (If Applicable)
Male
Female
Individual NPI:
Number:_______________Exp. Date:_________________
(mm/dd/yy)
If “YES” please provide
Email Address
__________________________________________
Name_____________________
Are you part of any Group?
NPI _____________________
N/A
YES
NO
________________________________
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 email address:
Do you perform e-Prescribing?
YES
NO
Do you have electronic records at your practice office?
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):
YES
NO
Mailing Address Line 2 (Suite, Room, etc.)
City / Town
City:
State:
Telephone:
Fax:
Email Address (if applicable):
SECTION 1C. - PRACTICE INFORMATION
1. Do you perform home visits?
Yes
If “Yes”, Complete 1C1.
Zip Code:
No If “No”, 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
1.
2.
3.
4.
5.
6.
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Zip
Provider Application Form-Physicians and Other Health Care Practitioners
02-2015
SECTION 1C2. - PRACTICE OFFICE INFORMATION (OFFICE 1)
Primary Office Address (Street Name and Number) :
City:
State:
Practice Name (if applicable)
Telephone:
Fax:
Name and Title of Contact Person (if other than provider)
Contact Person
Phone Number
Zip Code:
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
Storage Facility Address Line 1 (Street Name and number):
Storage Facility Address Line 2 (Suite or Room):
Telephone Number:
Office Hours
AM Hours
Former Patients
City/Town:
State:
Fax Number:
Monday
Zip Code
Email Address:
1C3 - PRACTICE OFFICE HOURS
Wednesday
Thursday
Tuesday
Both Current and Former Patients
Friday
Saturday
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:
Practice Name (if applicable)
Telephone:
Fax:
Contact Person
Phone Number
Zip Code:
1D1 – MEDICAL STORAGE FACILITY
Medical Record Storage Facility (Check One):
Same as Physical
If no, please complete below, and please indicate for
Current Patients
Storage Facility Address Line 1 (Street Name and number):
Storage Facility Address Line 2 (Suite or Room):
City/Town:
Telephone Number:
Fax Number:
Former Patients
State:
Both Current and Former Patients
Zip Code:
Email Address (If Applicable):
1D2 - PRACTICE OFFICE HOURS
Office Hours
AM Hours
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
PM Hours
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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 §420.200). Roster needs to include list of healthcare professionals rendering services.
Name
(Father's last name, Mother's last name, First Name,
MI)
Professional
License Exp. Date
(if applicable)
Professional License #
(if applicable)
Title
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?
Yes
No
N/A
If you answered “No” or “N/A” to the question above please proceed to next Section below, if you answered, “Yes”, continue below.
Do you have any medical equipment that you use as part of your practice?
Yes
No. If “Yes” 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?
provide a list of such equipment. (Attachment III)
Yes
No. If “Yes”,
SECTION 1G. - HIGHEST LEVEL OF EDUCATION
Highest Level of Education Name: ________________________
Graduation Date (mm/dd/yy):
Specialty Attained (Highest Level):
Highest Level of Education Address: ______________________
________________________
_________________________
Are you a foreign medical school graduate and have an ECFMG Certificate?
Yes
Is certified for Acupuncture?
No
If Yes - ECFMG number: ________________________
Serves patients with Autism?
Yes
Yes
No
No
1G1 – BOARD CERTIFICATION
Yes
No
ABMS Board Certification Specialty: _______________________________ Expiration Date: __________________________
ABMS Board Certification Specialty: _______________________________ Expiration Date: __________________________
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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.)
From (mm/yr.)
To (mm/yr.)
From (mm/yr.)
To (mm/yr.)
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 Yes, list the name (s) of an in network physician or facility below:
Hospital/Group Name
Location
Hospital/Group Name
Location
Yes
No, If “No” skip to next section.
Active
Pending
Active
Pending
Associate
Provisional
Associate
Provisional
Courtesy
Staff
Courtesy
Staff
SECTION 1J. - CLINICAL REFERRAL
Please list all clinic referral affiliations (hospital, clinics, groups, PHO/IPAs, etc.) or covering physicians:
Hospital/Group/Clinic Name
Location
Hospital/Group/Clinic Name
Location
N/A
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?
Yes
No
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.
Yes
No
If “Yes,“ please explain __________________________________________________________________________________________
______________________________________________________________________________________________________________
SECTION 1N. - COMPLETE PROFESSIONAL LIABILITY INSURANCE INFORMATION
Present Carrier’s Name _ ____________________________
Policy Number ______________ Policy Limits__________/__________
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Effective Dates – mm/dd/yy (From)____________(To)______________
02-2015
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?
Yes
No
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?
Yes
No
If Yes 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 "Yes" or "No". If any of the questions
are answered "Yes", 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
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
G. Ever been convicted of any crime (excluding traffic or parking violations) or pending any litigation for an alleged crime?
Yes
No
H.
Yes
No
Yes
No
Yes
No
Yes
No
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?
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 “ Yes” to any question above, please complete Section 2B.1, then proceed to and all other
questions in section 2.
Section 2B.1:
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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)
/
/
/
Medicaid
Medicare
Other: Specify: _____________________
DATE(s) OF REINSTATEMENT(s)
(If Any)
(Month/Day/Year)
/
/
/
/
/
/
/
/
/
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
State
Medicaid
Medicare
Other: Specify: ______________________
EFFECTIVE DATE(S) OF
(Conviction, Exclusion, Revocation or
Suspension)
Month/Day/Year
/ /
/ /
/ /
DATE(s) OF REINSTATEMENT(s)
(If Any)
Month/Day/Year
/
/
/
/
/
/
TYPE OF OFFENSE AND DISPOSITION:
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?
Yes
No
If yes, provide information in Section 2C.1; If No, 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
State
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).
Yes
No
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
Date Issued
(Month/Day/Year)
/ /
Agency
$
$
/
Address (Street Name or Suite and Number)
Medicare Identification Number
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Date to be Paid in Full
(Month/Day/Year)
/ /
/
City
Tax identification number (Required)
/
State
/
Zip Code
NPI
02-2015
SECTION 3. DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST INFORMATION (42 CFR 455.101-455.106; 42 CFR 420.201-420.206)
According to the Code of Federal Regulations title 42, part 455, sections 101-106 AND part 420, sections 201-206, 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
Federal Tax Identification Number
NPI
State
Zip Code
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 455.106) (Should be verified through appropriate
HHS-EPLS-OIG website).
NAME
TITLE
ADDRESS
YES 
NO 
DESCRIPTION
A.
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 455.105). If response is NO, continue to question #3.
NAME
YES 
NO 
ADDRESS
A.
B.
C.
D.
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 455.105)
NAME
N/A 
ADDRESS
A.
B.
C.
D.
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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 455.105)
YES 
NO 
NAME
ADDRESS
DESCRIPTION OF BUSINESS TRANSACTION
A.
B.
C.
D.
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 455.104)
NAME
ADDRESS
A.
B.
C.
D.
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 455.104)
YES 
NO 
NAME
RELATIONSHIP
A.
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 455.104)
NAME
YES 
NO 
ADDRESS
A.
B.
C.
D.
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.
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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: ______________________ (Note: 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)
Billing Agency Address (Street Name and Address)
Telephone Number
Doing Business As (DBA) name (If applicable)
Tax ID Number or Social Security Number
(required)
Fax Number (If Applicable)
City
E-mail Address (If Applicable)
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):
Address (Street Name or Suite and Number)
Billing Person Date of Birth (mm/dd/yy)
City
Telephone Number:
State
Fax Number:
Zip Code
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: ____________________________________
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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:
Specialty:
Middle Initial:
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):
IF GROUP:
Tax ID of Group or
IF CORPORATION:
NPI of Group or
First Name:
List Tax ID number:
(Corporation or Group)
Tax ID Corporation: (Check one)
List NPI Number:
(Corporation or Group)
NPI Corporation: (Check one)
IF INDIVIDUAL:
NPI of Individual: (Check one)
Payee Address:
Telephone number
Middle Initial
List NPI Number:
(Individual)
City
State
List S.S.Number:
(Individual)
ZIP Code
Fax number
Contact Person Telephone
Number
__________________________________________
Provider Name (Please Print)
__________________________________________
Provider Signature
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___________________________
Date
02-2015
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
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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 Signature
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___________________________
Date
02-2015
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 Signature
Page 13 of 16
___________________________
Date
02-2015
ATTACHMENT I
LIST OF AUTHORIZED ORGANIZATIONS
TRIPLE-S SALUD, INC,
TRIPLE S- ADVANTAGE, INC.
TRIPLE S- ADVANTAGE SOLUTIONS, INC.
Page 14 of 16
02-2015
ATTACHMENT II
INSTRUCTIONS FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST
(42 CFR 455.101-455.106; 42 CFR 420.201-420.206) According to the Code of Federal Regulations title 42, part 455, sections 101-106 AND part 420, sections 201-206, 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
02-2015
ATTACHMENT III
Provider Name ____________________________________
NPI ________________________
IMAGING PRODUCTION IN HOUSE AVAILABLE EQUIPMENT LISTING
YES/NO
TYPE
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
02-2015

participating provider credentialing application physicians and other

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