application to participate as a health care provider · application to participate as health care...

APPLICATION TO PARTICIPATE AS A

HEALTH CARE PROVIDER

Please submit application to:

[email protected]

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Application to Participate as Health Care Provider

INSTRUCTIONS

A prospective provider must apply for and be credentialed with Trillium Health Resources to qualify for reimbursement of services provided to Trillium Health Resources members.

THE CREDENTIALING PROCESS INCLUDES THE FOLLOWING STEPS: Provider completes and signs the Credentialing Application and returns it along with the required documentation to [email protected]

A Credential Application is considered to be invalid and must be returned to the provider for correction and/or for additional information if:

All spaces in the application have not been completed. Must put N/A or Not Applicable

The Signatures, where required, are not original and dated within 180 days.

The Signatures are not by the individual applicant or, where applicable, an authorized agent for the entity.

The text has been altered, highlighted, struck through, or obstructed through the use of correction fluids.

The responses are illegible.

The National Provider Identifier is not a valid number.

Any of the documents or pages that comprise the Credentialing Application are missing.

Any of the requested information in any of the documents that comprise the Credentialing Application are missing.

NC Tracks enrollment is incomplete or missing service location, taxonomy, or health plan, as required.

CHECKLIST - Before submitting the Credentialing Application, ensure the necessary components are included

in the following order:

Attestation Statement

Insurance Attestation

Insurance Information:

Copy of Certificate of Insurance or Letter of Intent from Carrier

Proof of Auto Insurance for Company Vehicles

Proof of Auto Insurance For Employee Vehicles if Employees Transport Members

Deficit Reduction Act Attestation

Code of Ethics

Background Authorization form(s) CEO, CFO, Medical Director, Managing staff

Trading Partner Agreement

Provider Direct System Administrator Form

EFT Authorization with Voided Check or Bank letter & W-9

Copy of Accreditation Certification

Copy of Articles filed with the NC Secretary of State

Copy of an Organizational Flow Chart including all owners of more than five percent (5%) interest and

all parent, sister, and subsidiary entities in the entire chain of ownership up to the ultimate owner of the

holding company.

Policy for completing background checks on owners, directors, officers, administrators, and staff

Copy of the NPI Certification Letter

Evidence of current DEA Certificate/State controlled dangerous substance certificate (if applicable)

Copy of Facility License for each site (If applicable)

Copy of Practice License for Professionals

Required Written References:

Fiscal Operations of the organization (one reference)

Clinical Operations of the organization (one reference)

Service Provision (2 references from individuals receiving services from the organization)

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Date of

Application:

Agency (Requires

Accreditation)

Group (Group of Practitioners providing

Outpatient Services, Not Accredited)

1. Legal Name of Organization (as used for tax reporting purposes/as listed with the NC Secretary of State):

2. Federal Tax ID #:

Federal Tax Status:

Not for Profit For Profit 501 C 3

3. NPI: 4. Taxonomy:

5. Organization Address (Mailing)

Address:

Street City State Zip+4

6. Number of years doing business under this name?

Has the organization ever been in business under a different name? Yes No

If yes, Name:

7. Website:

8. Primary Contact: Title:

Phone #: Fax #: Email:

9. CEO/Executive Director:

10. Clinical Director:

11. Medical Director:

12. Organization Legal Entity Type:

C-Corporation General Partnership Cooperative

S-Corporation Sole Proprietorship Not for Profit

Limited Liability Corporation Limited Liability Partnership Government

13. Is the organization accredited? (If yes, please attach verification of accreditation) Yes No

JCAHO: Years accredited: Expiration Date:

CARF: Years accredited: Expiration Date:

COA: Years accredited: Expiration Date:

CQL: Years accredited: Expiration Date:

Other:

Refer to SECTION 10.15A. (c) Article 3A of Chapter 122C of the General Statutes.

SECTION 1: CORPORATE INFORMATION

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14. Has the organization ever been sanctioned, placed on probation, or lost accreditation or certificationStatus? (If yes, please attach an explanation of the circumstances and how it was resolved.)

Yes No

15. Liability Insurance:

a. Has the organization ever had a claim against it?

Yes No

(If yes, please list the name and amounts of the insurance and disposition.)

b. Are there any current, unsettled claims? Yes No

(If yes, please attach an explanation.)

c. Is the organization aware of any circumstances that may result in a claim or suit?

(If yes, please attach an explanation.) Yes No

d. Has the organization ever had a policy cancelled?

(If yes, please attach an explanation.) Yes No

16. Has there ever been any action or investigation against any owner or qualified professional in the organization relating to any of the following? (If yes, please attach an explanation.)

a. License? Yes No

b. Certification? Yes No

c. Registration? Yes No

d. Privileges? Yes No

e. Billing Organizations? Yes No

f. Sanctions? Yes No

17. Have any adverse actions been filed against the organization by any of the following? (If yes, please attach an explanation.)

a. Medicaid? Yes No

b. Medicare? Yes No

c. Other Insurance? Yes No

18. Has anyone in the organization who has an ownership, managerial, or clinical role ever been sanctioned by any professional or government organization for any of the following in any state or country? (If yes, please attach an explanation.)

a. Violation of Ethics? Yes No

b. Professional Misconduct? Yes No

c. Unprofessional Conduct? Yes No

d. Incompetence? Yes No

e. Negligence? Yes No

19. Is the organization aware of any circumstances that may result in such an action? (If yes, please attach an explanation.)

Yes No

20. Has the organization ever had a contract cancelled by another LME/Area Authority/County Program in North Carolina, or similar entity in another state? (If yes, please attach an explanation.)

Yes No

21. Has anyone in the organization with an ownership, managerial or clinical role ever been convicted of a felony or misdemeanor, or is under investigation with respect to such conduct? (If yes, please attach an explanation.)

Yes No

SECTION 1: CORPORATE INFORMATION Continued

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1. List all shareholder/partners (including self) who have 5% or more ownership (or whose spouse, parent, child

or sibling as such an interest) AND all individual officers, directors, managers, all board members, and

Electronic Funds Transfer (EFT) authorized individuals and information requested on each. (This page may be

duplicated if necessary).

Name: Address:

Title: SSN: License #:

Date of birth: % Owner:

Check business relationship that applies:

Owner Shareholder Partner Manager EFT Auth Staff

Check relationship to enrolling provider (if applicable).

Spouse Parent Child Sibling

Name: Address:







Name: Address:







Name: Address:







SECTION 2: OWNERSHIP INFORMATION

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2. Please include the following information if not included above:

CEO/President:

SSN: License #:

Address:


CFO/Finance:

SSN: License #:

Address:


3. Identify other providers, if any, which are owned or operated by the applicant under the same owner

name.

Provider Name:

Address:


Relationship Type:

Nursing Home Home Health Agency Community Based Residential Facility

Hospital Other:

4. Is the applicant a subsidiary company, either wholly or partially owned by another

organization or business?

If yes, provide the following information: Yes No

Legal Business Name – Parent Company:

Type of Ownership:

SECTION 2: OWNERSHIP INFORMATION Continued

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A Site is a physical location where supervision and/or management of services occur. Please attach the facility site license if applicable. Complete this section for each service that the organization is seeking to provide AND for each site. (This section may be duplicated if necessary).

1. Site Name:

Address:


2. Phone: 3. Fax #:

4. Email:

5. NPI:

6. Taxonomy:

7. Hours:

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

8. Services Rendered – PER SITE: Please list the services that will be provided at each site:

Service Code Service Description

SECTION 3: SITE SPECIFIC INFORMATION

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9. Information about the Facility/Site Director or Supervisor:

Name:

Education: Credentials:

Have they ever completed an application to Trillium Health Resources? Yes No

If yes, what year: What was the outcome?

10. Is this site licensed by any of the following? (If yes, attach a copy of each license.)

a. DHSR: Yes No License #: State:

b. DSS: Yes No License #: State:

c. Other: Yes No Type:

License #: State:

11. Is this facility/site staffed and equipped to serve any of the following? (This question is NOT optional. Please check either Yes or No.)

a. Physically Handicapped: Yes No

b. Blind/Visually Impaired: Yes No

c. Deaf and/or Hearing Impaired: Yes No

d. Sexually Aggressive: Yes No

e. Behaviorally Disruptive: Yes No

f. Foreign Languages: Yes No

Please Specify:

12. Coverage: Please indicate what arrangements the organization has to cover member emergency situations during nights, weekends, and holidays.

13. Physician Coverage: Please indicate what arrangement the organization has made, or are planning to make, to cover the organization for members who need psychiatric evaluation or psychiatric medication. List psychiatrist/physician who will see the members.

Name: Phone:

Name: Phone:

SECTION 3: SITE SPECIFIC INFORMATION Continued

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If the organization has Licensed Practitioners or Provisional Licensed Practitioners it is the responsibility of the organization to ensure that each Practitioner completes and submits the “Credentialing Application to Participate as a Health Care Practitioner” (if Practitioner is not currently credentialed with Trillium Health Resources) or the “Request to Add a Licensed Practitioner” (if Practitioner is currently credentialed with Trillium Health Resources).

Please list all Licensed Practitioners, their Taxonomy #, NPI #, and License Type who will be seeing Trillium members. (This page may be duplicated if necessary).

Licensed Practitioner License Type NPI Taxonomy

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

SECTION 4: PRACTITIONER INFORMATION

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INSURANCE REQUIREMENTS AND ATTESTATIONS PROVIDERS

The CONTRACTOR shall purchase and maintain insurance as listed below from a company, which is licensed and

authorized to do business in the State of North Carolina by the North Carolina Department of Insurance. Insurance

policies shall require that the coverage cannot be suspended, voided, canceled or reduced in coverage or limits

without thirty (30) days prior notice to the LME. Any loss of insurance shall be the basis of a payback to the LME for

services billed during this period and may result in the termination of this Contract. All insurance requirements of this

Contract must be fully met unless specifically waived in writing by LME.

i. The CONTRACTOR shall purchase and maintain professional liability insurance protecting the CONTRACTOR and

any employee performing work under the Contract for an amount of not less than $1,000,000.00 per occurrence

and proof of coverage at or exceeding $3,000,000.00 in the annual aggregate. The Provider’s professional liability

insurance policy shall name the LME as additional insured. In the event that the CONTRACTOR discovers that a

claim, suit of criminal/administrative proceeding has been brought or may be brought against the CONTRACTOR

and/or Practitioner relating to the quality of services provided under this Agreement, then CONTRACTOR shall notify

LME within ten (10) days and LME will determine whether to terminate this Agreement.

We have provided a Certificate of Insurance showing that we meet this requirement.

ii. Comprehensive General Liability: Bodily Injury and Property Damage Liability Insurance shall protect the

CONTRACTOR and any employee performing work under the Contract from claims of Bodily Injury or Property

Damage, which may arise from operations under the Contract. The amounts of such insurance shall not be less

than $1,000,000.00 per Occurrence/$3,000,000.00 per Aggregate unless Provider, with prior written approval of the

LME, names the LME as an additional insured in which case limits of no less than $1,000,000.00 each occurrence

and $1,000,000.00 in the annual aggregate would be acceptable. Personal and Advertising Injury/$50,000.00 Fire

Damage. The insurance shall not include exclusion for contractual liability.


iii. Automobile Liability: Automobile Bodily Injury and Property Damage Liability Insurance covering all owned, non-

owned, and hired automobiles for limits of not less than $1,000,000.00 each person and $1,000,000.00 each

occurrence of Bodily Injury Liability and $1,000,000.00 each occurrence of Property Damage Liability. Policies

written on a combined single limit basis should have a limit of not less than $1,000,000.00.

We have provided a Certificate of Insurance showing that we meet this requirement. OR

We do not transport recipients.

iv. Workers’ Compensation and Occupational Disease Insurance, Employer’s Liability Insurance: CONTRACTOR with

three (3) or more employees shall secure Worker’s Compensation and Occupational Disease Insurance. The

insurance coverage must meet the statutory requirements of the State of North Carolina; and Employer’s Liability

Insurance for an amount of not less than: Bodily Injury by Accident $100,000.00 each Accident, Bodily Injury by

Disease $100,000.00 each Employee, and Bodily Injury by Disease $500,000.00 Policy Limit.


v. Certificate of Coverage: The CONTRACTOR shall provide the LME with Certificates of Insurance Coverage

consistent with the Contract within thirty (30) days following the effective date of the Contract and on an annual

basis within ten (10) days of the anniversary date of the Contract, and shall provide a new Certificate within ten

(10) days of the expiration date if the Insurance Certificate expires during the contract period. Certificates shall

contain the provision that the LME is given thirty (30) days written notice of any intent to amend or terminate by

either the CONTRACTOR or the insurance company. The CONTRACTOR shall notify the LME of any cancellation or

material change, within forty-eight (48) hours, and within ten (10) days written notice to the certificate holder (THR

LME) of any change in insurance provider during the period of the Contract. If the CONTRACTOR changes

insurance providers during the performance period of the Contract, the CONTRACTOR shall provide evidence to

the LME that the LME will be indemnified to the limits specified above for the entire performance period of the

Contract, either under the policy or a combination of old and new policies. THR LME shall be identified as a

“Certificate Holder” and included on the Certificate of Liability Insurance.

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vi. Liability Coverage: Liability insurance may be on either an occurrence basis or on a claims-made basis. If the policy

is on a claims-made basis, an extended reporting endorsement (tail coverage) for a period of not less than three

(3) years after the end of the contract term, or an agreement to continue liability coverage with a retroactive date

on or before the beginning of the contract term, shall also be provided.

vii. Waiver of Subrogation: CONTRACTOR shall obtain and provide to LME waivers from CONTRACTOR’S workers’

compensation and occupational disease and commercial general liability carriers of any right of recovery that

such liability carriers may have because of payments made by them for injury or damage arising out of work done

by CONTRACTOR under this Contract, including contract documents issued under this Contract such as an LME

Treatment Authorization Request Form.

PRINT NAME / TITLE (OWNER, MANAGER, CFO, ETC) SIGNATURE

PROVIDER DATE

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DEFICIT REDUCTION ACT ATTESTATION

The Deficit Reduction Act (DRA) of 2005, which went into effect January 1, 2007, required specific changes to states’

Medicaid programs. One of the changes is the requirement for employee education about false claims recovery.

Section 6032 of the DRA amended the Social Security Act, Title 42, United States Code, Section 1396(a) by inserting an

additional relevant paragraph (68). This paragraph is cited below; in summary it requires any entities that receive or

make annual payment under the Medicaid State Plan of at least five million dollars to have detailed, specific written

policies established about the Federal and State False Claims Acts for their employees, agents and contractors.

Specifically, §1396(a)(68) of the Social Security Act requires that any entity that receives or makes annual payments

under the State plan of at least $5,000,000, as a condition of receiving such payments, shall –

A. Establish written policies for all employees of the entity (including management), and of any contractor or

agent of the entity, that provide detailed information about the False Claims Act established under section

3729 through 3733 of title 31, United States Code [31 USCS §3729-3733], administrative remedies for false claims

and statements established under chapter 38 of title 31, United States Code [31 USCS §. 3801 et seq.], any State

laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections

under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in

Federal health care programs (as defined in section 1128B(f)[42 USCS § 1320-7b(f)]);

B. Include as part of such written policies, detailed provisions regarding the entity’s policies and procedures for

detecting and preventing fraud, waste, and abuse; and

C. Include in any employee handbook for the entity, a specific discussion of the laws described in subparagraph

(A), the rights of the employees to be protected as whistleblowers, and the entity’s policies and procedures for

detecting and preventing fraud, waste, and abuse;

Effective January 1, 2007, all providers who meet the above conditions are required to certify that they are in

compliance with §1396(a)(68) of the Social Security Act as a condition of enrollment in the North Carolina Medicaid

Program.

As a North Carolina Medicaid provider, or the owner/ operator/ manager of a North Carolina Medicaid provider entity,

I certify that our entity has read and understands the above requirements. I also certify that if our entity receives or

makes annual payments under the State plan of at least $5,000,000 we have complied with and established written

policies and procedures that provide detailed information concerning the Federal False Claims Act, 31 USC 3729 et

seq., administrative remedies for false claims and statements established under 31 USCS §. 3801 et seq., and any North

Carolina State laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower

protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse

in Federal health care programs.

I further certify, when the above conditions apply, that our entity’s written policies include detailed provisions regarding

our policies and procedures for detecting and preventing fraud, waste, and abuse; and that our employee handbook

contains a specific discussion of the Federal and State False Claims Acts, the rights of the employees to be protected

as whistleblowers, and our policies and procedures for detecting and preventing fraud, waste, and abuse.

Copies of any and all training manuals, written policies and procedures for detecting and preventing fraud, waste,

and abuse, and employee handbooks will be maintained on-site for a minimum of five (5) years for inspection and

auditing by the Division of Medical Assistance.


PROVIDER DATE

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CODE OF ETHICS

PREAMBLE

The Trillium Health Resources provider network shall facilitate an open exchange of ideas, share values, goals,

vision, and promote collaboration and mutual accountability among providers. The provider network strives to

achieve best practices to empower members within our community to achieve their personal goals.

Assure that staff adhere to the Code of Ethics

Provide support to other member agencies

Advocate for the further development of resources on a local and state level for members served

PURPOSE OF CODE

Trillium Health Resources supports and encourages a network community which has an expectation that

providers will adhere to the highest ethical standards.

PHILOSOPHY

Trillium Health Resources network providers agree to abide by the Code of Ethics. Member Agencies shall:

Become familiar with and encourage their Board of Directors, Owners, and Agency personnel to

adhere and follow the Code of Ethics

Agree that actions which violate the Code of Ethics would be considered unethical

Agree that a lack of knowledge is not a defense for unethical conduct

Strive to achieve the highest standards of professional conduct

Acknowledge that all member agencies should be committed to best practices in their specific area

through involvement with continued education, provider networking, and review of relevant research

Have an obligation to report in writing to the LME/MCO any direct knowledge of perceived violations of

the Code of Ethics.

Offer age appropriate services which promote dignity and empower the individual

Reflect the beliefs, values, heritage, and customs of individuals supported by offering culturally

competent services

CORE VALUES AND ETHICAL PRINCIPLES

The mission of the Trillium Health Resources provider network is founded in a set of core values. Network

providers embrace the core values; which serve as the foundation of the provider network. The principles set

forth ideals to which all network providers should aspire.

VALUE: INTEGRITY

ETHICAL PRINCIPLE: Provide accurate and truthful representation.

Network providers will not knowingly permit anyone under their supervision to engage in any practice

that violates the Code of Ethics.

Network providers will not engage in dishonesty, fraud, deceit, misrepresentation of themselves or other

providers, or any form of conduct that adversely reflects on their profession, the provider network, or on

the network providers ability to support members professionally.

Network providers will not commit unethical practices that include, but are not limited to, deceptive

billing, falsification of documentation, commission of a felony, gross neglect and fiduciary impropriety.

VALUE: COMPETENCE

ETHICAL PRINCIPLE: Honor responsibilities to achieve and maintain the highest level of professional competence

for themselves and those in their employ.

Network providers will represent their competence within their scope of practice.

Network providers will engage in only those aspects of the profession, that are within the scope of their

competence, considering their level of education, training, and experience.

Network providers will allow individual staff to provide only those services that are within the staff

member's competence, considering the employee's level of education, training, and experience.

Network provider agencies will demonstrate compliance with state and federal rules, regulations and

laws regarding standards for training and credentials for supports provided.

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VALUE: PROFESSIONAL CONDUCT

ETHICAL PRINCIPLE: Promote dignity and autonomy. Maintain collaborative relationships. All professional

relationships should be directed to improving the quality of life of the individuals who receive supports and

services from the network agency.

Network providers will not participate in activities that produce a benefit for themselves over the

individuals they support or may potentially support, always giving priority to professional responsibility

over any personal interest or gain.

Network providers will make all reasonable efforts to prevent any incidents of abuse, neglect and

exploitation.

Abuse means the infliction of mental or physical pain or injury by other than accidental means, or

unreasonable confinement, or deprivation by an employee of services, which are necessary to the

mental or physical health of the individual. Temporary discomfort that is a part of an approved and

documented treatment plan or use of a documented emergency procedure shall not be considered

abuse.

Neglect means the failure to provide care or services necessary to maintain the mental or physical

health and well-being of the individual.

Network providers will promptly report and thoroughly investigate all allegations of abuse, neglect, and

exploitation.

Under no circumstance will the support relationship between the program, staff, and individuals

receiving services, and/or their families or legal guardian be exploited.

Exploitation is defined as the illegal or unauthorized use of a service user or a service user's resources for

another person's profit, business or advantage.

Network providers will train staff to recognize and report any suspected incidents of abuse and neglect

and exploitation.

VALUE: INDIVIDUAL VALUE, DIGNITY, AND DIVERSITY

ETHICAL PRINCIPLE: Provide supports and services, which promote respect and dignity of each individual

served.

Network providers will comply with all Federal and State rules and laws related to confidentiality and

protected health information, including but not limited to, N.C.G.S. 122C; HIPAA; and the TRILLIUM

HEALTH RESOURCES contract.

Network providers will not discriminate in their relationships or services provided to individuals receiving

supports, contractors, and colleagues on the basis of race or ethnicity, gender, age, religion, national

origin, sexual orientation, or disability.

Network providers will provide individuals and families a means of submitting grievances that is fair and

impartial.

Network providers will comply with N.C.G.S.35A-1201, which allows for all people to be involved in

decisions and choices that impact their lives.

Network providers will make all reasonable efforts to ensure individuals and families participate in the

development and revision of any plan for services.

Network providers will not abandon individuals and families.

Network providers will consistently demonstrate efforts to assure that their services eliminate the effects

of any biases based upon individual and cultural factors.

Network providers will support the recovery and self-determination of each individual.

VALUE: SOCIAL JUSTICE

ETHICAL PRINCIPLE: Assure the rights of individuals receiving supports and others who make decisions regarding

services have complete information on which to make their choices.

Network providers will accurately portray their services and capacities through public and private

statements.

Network providers will not engage in false and deceptive representation of their services.

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Network provider's marketing strategies will not offer inducements to primary individuals receiving

supports or their legal representatives in exchange for business gained.

Network providers will accurately portray their ownership, Board of Directors and management through

public and private statements.

Network providers will follow required laws and standards regarding the hiring of staff.

Network providers will not make initial contact with employees of other providers for the purpose of

offering employment to that individual employee for the purpose of gaining clients. This does not

preclude the individual client to make a choice.

Network providers will use the standards means of advertising for hiring staff.

VALUE: SOCIAL CAPITAL

ETHICAL PRINCIPLE: Network providers support the importance of social capital for each individual supported.

Network providers will support and promote opportunities for individuals they support to develop valued

relationships with members of the community in which they live or work.

Network providers will support and promote opportunities for individuals they support they be treated

with respect and dignity within the community they live or work.

Network providers will support and promote opportunities for individuals they support developing roles in

the community in which they live or work.

Network providers will discuss known violations of standard ethical practices by members with the

offending colleague or agency director. In the event that this does not end in resolution of the issue, the

member shall make a formal complaint to the LME.

VALUE: PARTNERSHIP

ETHICAL PRINCIPLE: Network providers will work together in partnership to develop and achieve individual

desired outcomes.

Network providers will work in partnership:

o To assure continuity of care for members, and

o To assure linkage for services, and

o With members, stakeholders, parents, significant others, and TRILLIUM HEALTH RESOURCES to

support the attainment of each individual's goals.

o Network Providers shall collaborate to share resources that enhance the functions of the

Network to develop solutions for gaps in services.

Approved by:

By signing below, I am attesting that I have read, understand and agree to comply with Trillium Health

Resources "Provider Network Code of Ethics".


PROVIDER DATE

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BACKGROUND CHECK AUTHORIZATION FORM

Name: Previous Name: First Middle Last

Current Address: Street City State Zip Code

Number of years are residence?

1st Previous Address: Street City State Zip Code


2nd Previous Address: Street City State Zip Code


Social Security Number: Date of Birth:

Driver's License # and State Issued:

Email Address: (may be used for official correspondence)

Consumer Disclosure I understand that Trillium Health Resources may rely on one or more consumer reporting agencies such as IntelliCorp, Inc. to obtain a consumer report(s) or investigative consumer report(s) (criminal background check, Databank, etc.) for credentialing purposes and I attest that all personal data provided is true, accurate, and complete.

Applicant Authorization I hereby authorize Trillium Health Resources to obtain and rely upon consumer reports or investigative consumer reports for the purpose of credentialing.

Applicant's Signature Date

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ATTESTATION STATEMENT

I certify the information submitted in this entire application, as well as any attachments or supplemental

information, is complete, accurate, and current to my best knowledge and belief as of the date of signature

below. I fully understand that any misstatements in or omissions from this application may constitute cause for

denial of membership or termination of a resulting participation agreement. A photocopy of this application has

the same force and effect as the original.

By application for membership in Trillium Health Resources, I signify my willingness to appear for interview in regard

to my application. I authorize Trillium Health Resources to consult with administrators and members of the medical

staffs of hospitals or institutions with which I have been associated and with others, including past and present

malpractice carriers, who may have information bearing on the questions in this application. Upon request, I will

obtain and provide to Trillium Health Resources materials pertaining to my qualifications and competence,

including, materials relating to complaints filed, any disciplinary action, suspension, or action to curtail my

medical- surgical privileges. I further consent to the inspection by representatives of Trillium Health Resources of

all documents that may be material to an evaluation of my professional qualifications and competence.

I understand and agree that I, as an applicant, have the burden of producing adequate information for proper

evaluation of my professional competence, character, ethics, and other qualifications and for resolving any

doubt about such qualifications. I release from liability all representatives of Trillium Health Resources for their acts

performed in good faith and without malice in connection with evaluating my application and my credentials

and qualifications, and I release from any liability, all individuals and organizations that provide information to

Trillium Health Resources in good faith and without malice concerning this application and I hereby consent to

the release and verification of information relating to any disciplinary action, suspension, or curtailment of

medical-surgical privileges to Trillium Health Resources.

I understand that if my application is rejected for reasons relating to my professional conduct or competence,

Trillium Health Resources may report the rejection to the appropriate state licensing board and/or National

Practitioner Data Bank. In the event I am accepted for participation in Trillium Health Resources Network, I hereby

consent to Trillium Health Resources for inspection of my patient records relating to Trillium Health Resources

enrollees as necessary for its peer and utilization review purposes as permitted by state or federal law and

regulation. I further agree to notify Trillium Health Resources in a timely manner (not to exceed 30 days) of any

changes to the information requested on the initial application.


PROVIDER DATE

PLEASE SIGN AND DATE THIS ATTESTATION STATEMENT

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