provider application - america's ppo · d:\kpo docs\appo...

$: PROVIDER APPLICATION - America's PPO · D:\KPO Docs\APPO Documents\Credentialing_Application.doc 1 PROVIDER APPLICATION (Please Print) CONTRACT LEGAL ENTITY Name$
D:\KPO Docs\APPO Documents\Credentialing_Application.doc

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PROVIDER APPLICATION (Please Print) CONTRACT LEGAL ENTITY Name: ________________________________________________________________________________ Address: _____________________________________________ _____________________________________________ County: ________________________ Requested Effective Date: _____________________________________ Phone: ____________________________ Fax: ______________________________ Federal Tax ID Number: ________________________________ NPI: ________________________ * Please complete attached W-9 forms and turn in with application BILLING INFORMATION Billing Address: __________________________________________________ County: ______________

__________________________________________________ Phone: ______________ Billing Manager: __________________________________________________ Phone: ______________ Business Office Manager: __________________________________________ Phone: ______________ Email Address: _________________________________________________________________________

(Attach check for application fee here)


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PHYSICIAN / PROVIDER INFORMATION ________________________________ _______ ___ ____________________________ _______ First Name MI Last Name Degree Date of Birth___________________ Gender: M / F Place of Birth: _______________________ SSN: ____________________________________ Medicare UPIN: _____________________ Specialty: ________________________________ OUTREACH / SECONDARY LOCATIONS (Please include street address, city, state, and the area code with phone number) Second _________________________________________________________ County: ______________ Office Address: ________________________________________________________ Phone: _______________ Third _________________________________________________________ County: _______________ Office Address: ________________________________________________________ Phone: _______________ Office Hours: M-F __________________________________ Sat. _____________ Sun. ______________ Able to submit claims electronically? Yes / No Contact Name: ____________________________ Phone: ________________________________ List any special clinic services (ie: laboratory/imaging services):__________________________________ List any languages spoken by clinic staff (other than English):____________________________________ List any allied health professionals employed with the clinic: Profession Name License/registration: Exp date 1.____________________________________________________________________________________ 2.____________________________________________________________________________________ 3.____________________________________________________________________________________ 4.____________________________________________________________________________________


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PROVIDER EDUCATION AND TRAINING Curriculum vitae may be attached in lieu of completing this section, if all requested information is included. Education: Institution Dates Degree & Attended Specialty Undergraduate School: _________________________________________ ________________ ______________ Medical School: __________________________________ ________________ ______________ Internship: ______________________________________ ________________ ______________ Residency: ______________________________________ ________________ ______________ Fellowship: _____________________________________ ________________ ______________ Board Certification: *Please attach a copy of Board Certification

*Please attach a copy of certificate of completion from residency or fellowship programs, or a letter from the Board verifying eligibility to take the certification exam

Specialty: _________________________________________ Board Certified Y N Date______________________ Name of Board_____________________________ Board Eligible: Y N Date of Exam _____________ Name of Board______________________________ Subspecialty: ____________________________________________ Board Certified Y N Date_____________________ Name of Board______________________________ Board Eligible: Y N Date of Exam_____________ Name of Board______________________________ How long have you been a practicing physician in the local area? _________________________________ Languages spoken (other than English):______________________________________________________ Work History: Name of Organization: __________________________________________________________________________ Address: ______________________________________________________________________________ Position Held: __________________________________ Dates: ______________________________


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Name of Organization: __________________________________________________________________________ Address: ______________________________________________________________________________ Position Held: __________________________________ Dates: ______________________________ Hospital Affiliations: Hospital % Admissions to each Type of privilege Primary: ________________________________ ___________________ _____________________ Others: _________________________________ ___________________ _____________________ ________________________________________ ___________________ _____________________ Professional Liability Insurance: _______________________________________________________ ____________________________ Malpractice Carrier (include copy) Policy Number _____________________________________ _________________ _____________________ Amount of coverage Eff Date Exp Date Licensure: ______________________________________________________________________________________ Sate Medical License Number (include copy) Exp Date ______________________________________________________________________________________ DEA Registration Number (include copy) Exp Date ______________________________________________________________________________________ National Board of Medical Examiners Number Date Is your practice limited to a specialty or subspecialty: If yes, please explain: ________________________ ______________________________________________________________________________________


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(Circle One)

YES NO Have your hospital privileges ever been refused, revoked, suspended or reduced? Y N Are you currently under review or have you ever been disciplined by any State Board or Medical Examiners or by any Professional Conduct Board: (If yes, please complete Exhibit Two) Y N Have any malpractice suites, arbitrations or other proceedings ever been instituted against you? (If yes, please complete Exhibit One) Y N Has your DEA certificate ever been suspended or otherwise limited? (If yes, please Complete Exhibit Two) Y N Has your license to practice medicine in any jurisdiction (state or county) ever been revoked, suspended or subject to probation or any conditions or limitations? (If yes, please complete Exhibit Two) Y N Are you an owner, partner, investor, or do you have a business interest in any clinical Laboratory, diagnostic, or testing center, surgicenter, or other business dealing with the Provision of health services, equipment or supplies? (If yes, please include the following information: Name of organization, tax identification number, address, phone number, type of organization, nature of business interest, and percent of ownership/investment) Y N Do you have any physical or mental health condition, treated or untreated which in any way impairs your ability to practice medicine to the fullest extent of your licensure and qualifications? (If yes, please attach explanation) Y N Do you have a chemical dependency/substance abuse problem, treated or untreated? (If yes, please attach explanation) Y N To the best of your knowledge, has any information pertaining to you ever been reported to the National Practitioner Data Bank? (If yes, please attach a copy of the report/s) Y N Have you ever been convicted of a felony or misdemeanor? (other than minor traffic Violations) Y N _____________________________________________________________ Printed Name _____________________________________________________________ ______________ Signature Date


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EXHIBIT ONE

MALPRACTICE DETAILS Please attach a copy of the actual legal document or complete the following. If you have been involved in more than one malpractice suite, please photocopy this form and complete one copy per occurrence. File number: ___________________________________________________________________________ Date of summons and complaint: __________________________________________________________ Date of incident: _______________________________________________________________________ Plaintiff(s) name: _______________________________________________________________________ Defendant(s) name: _____________________________________________________________________ Insurance company involved: _____________________________________________________________ Policy Number: ________________________________________________________________________ Complaint: ____________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Stage of suit_______________________________________________________ Date expected to be resolved: ________________________________________ Court Date: ______________________________________________________ Detailed outcome of suit (include dollar amount of any settlement):________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________


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EXHIBIT TWO

DISCIPLINARY ACTIONS Please describe any disciplinary actions taken by the State Board of Medical Examiners, Professional Conduct Board, medical organization, State or County agency. If you have been disciplined more than once, please photocopy this form and complete one form per occurrence. Date of original action: _____________________________________________________ Nature of misconduct: _________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Agency(ies) taking action:_________________________________________________________________ Action taken: __________________________________________________________________________ Specific restriction or orders with which to comply: __________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Subsequent action and date: ______________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________


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APPLICATION AUTHORIZATION

The undersigned, with the purpose of filing application to be considered for participation status with America’s PPO of Minnesota, attests that the enclosed information presented for review is truthful, accurate and complete. Therefore, it is understood that any deviation from completeness or false representation of required information, will result in delay or omission of the application for review. It is understood that the required $250 application fee is non-refundable, whether or not participation status with America’s PPO of Minnesota is granted. It is further understood that this fee covers the costs associated with the verification of information application review, and analysis processes. It is understood that America’s PPO will use this information in the application review process. It is further understood that the following criteria, but not exclusively, may be used in the evaluation of an applicant for potential inclusion within The America’s PPO provider network: a) The America’s PPO current need of an applicant’s specialty in the applicant’s geographic region, to

meet growing America’s PPO membership needs. b) Good Standing with the State Board of Medical Examiners and the governing agencies. c) Maintenance of current licensure, DEA Registration, and adequate malpractice insurance coverage. d) Commitment to The America’s PPO maximum authorized reimbursement, based on CPT-$ procedure

codes. With respect to the above, the undersigned understands the terms of application and has provided all relevant information in response to the application request. I hereby authorize all individuals, institutions and entities with which I have been associated to release relevant information to America’s PPO, and associated Third Party Payers. I agree to notify America’s PPO of any changes or updates to the information contained in this application during or, if accepted, after such acceptance to America’s PPO network within 15 days. I understand that all information contained within this application will be used in confidence and solely to review my application. I further understand that this application does not constitute an agreement, and grants to rights nor privileges until I receive notification of acceptance. Name: (Type or Print) ___________________________________________________________________ Signature: _________________________________________ Date: _______________________________ PLEASE RETURN TO: America’s PPO Attn: Provider Relations 7201 West 78th Street Suite 100 Bloomington, MN 55439