This form must be completed by each individual facility. For each form, complete all areas and attach additional sheets as necessary.

Transcription

1 FACILITY APPLICATION This form must be completed by each individual facility. For each form, complete all areas and attach additional sheets as necessary. PRACTICE INFORMATION COUNTY: Facility Legal Name: Physical Address: Phone Number: Address: Fax Number: Tax ID Number: Mailing Facility Name: Mailing Address: Payment Facility Name: Payment Address: Contract Facility Name: Contract Notification Address: Contract Administrator: Address: Phone Number: Fax Number: Will all services be billed under the above TIN: Yes No (provide explanation below) Billing Method: Manual Electronic (EDI) EDI Vendor: Practice Type: Professional Corporation Partnership Individual Practice How long has your company been in business: Years: Are you an independent practice under corporate sponsorship: Months: No Yes (provide info below) Copyright Rehab Provider Network 1 of 5

2 FACILITY SERVICE INFORMATION Within how many hours can a patient be seen for a new evaluation: What is the average waiting time in your office: What is your average daily volume of patients: Monday Day AM PM Tuesday Hours of operation: Wednesday Thursday Friday Saturday Sunday Average length of individual patient appointments: Ratio of professional staff to extenders or assistants : Is your center Medicare Certified: No Yes: Medicare Number: (Attach copy of Certification) Has your facility been accredited by any Agency: No Yes: List Agency: Please check the specialty services provided at this location: Physical Therapy Occupational Therapy Speech Therapy Back Schools Spinal Cord Program Womens Health Pain Management Work Hardening Work Conditioning Sports Medicine & Conditioning TMJ Specialty Wound Care Pre/Post Employment Testing Work Site Assessments/Job Analysis After-Care Pediatrics Certified Massage Therapy Vestibular Adult Neurological Prosthetics Orthotics Pool: Length: Width: Depth: Temp: Aquatic Therapy Access: Stairs Ladder Ramp Lift Functional Type: Capacity Evaluation (FCE) Facility License Required: No Yes: Date of Expiration: Lymphedema Care McKenzie Spine Therapy Certified Hand Therapy Other: Copyright Rehab Provider Network 2 of 5

3 PROFESSIONAL STAFF LIST ALL PROFESSIONAL STAFF WHO PROVIDE HEALTH CARE BILLABLE SERVICES TO PATIENTS AT YOUR FACILITY (ATTACH ADDITIONAL SHEETS IF NECESSARY) Last Name First Name MI Title State of License Languages: Do you employ bilingual staff: No Yes: PLEASE INDIVIDUALLY LIST EACH OWNER OF YOUR BUSINESS: Copyright Rehab Provider Network 3 of 5

4 PROFESSIONAL LIABILITY INSURANCE Attach copy of Policy Carrier Name: Policy Number: Does this policy cover all professional and support staff: No Yes Coverage Scope: Amount Aggregate: Effective Date: Amount Per Occurrence: Renewal Date: PROFESSIONAL LIABILITY CLAIMS HISTORY HAS THERE BEEN A CLAIM FILED AGAINST YOUR FACILITY RELATIVE TO YOUR PRACTICE WITHIN THE LAST FIVE (5) YEARS: No Yes: INSURANCE CARRIER: PROVIDE DETAILED, FACTUAL DESCRIPTION OF THE CASE: OCCURRENCE DATE: SPECIFY ANY SUBSEQUENT ACTIONS WHICH HAVE BEEN OR MAY BE TAKEN: WHAT IS/WAS THE OUTCOME OF THE PATIENT: LAST NAME FIRST NAME PRIMARY DEFENDANT CO-DEFENDANT OTHER: WHAT IS THE CURRENT STATUS OF THE DISPUTE: WHAT IS/WAS THE DOLLAR AMOUNT RESERVED/PAID BY YOUR CARRIER FOR THIS CLAIM: $ Copyright Rehab Provider Network 4 of 5

5 CERTIFICATION & RELEASE All the information submitted in this application is true and complete. I understand that misleading statements or material omissions may constitute cause to reject this application, or if subsequently discovered, to terminate my contract with Rehab Provider Network. I release from liability all representatives of Rehab Provider Network, any corporate affiliate of such corporation, and all officers, directors, employees, agents and representatives, for their acts performed in good faith and without malice in connection with evaluating the information provided in the Facility Application Form, my credentials and qualifications, and with delivering such information, credentials and qualifications to any third party in the course of business. I release from any liability any individuals or organizations who provide information to Rehab Provider Network in good faith and without malice concerning my professional competence, ethics, character and other suspensions, curtailment of privileges by any hospital, or other healthcare provider and by any federal or state licensing or regulatory authority and Rehab Provider Network. I further consent to the release of professional liability, malpractice, or other insurance information to Rehab Provider Network. Signature Date Printed Name Title Co-Owner Signature Date Co-Owner Printed Name Title Return completed applications to: Copyright Rehab Provider Network 5 of 5