Kaiser Permanente will notify you of our decision in writing within 30 days of our receipt of your application.

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1 Provider Application for Participation Instructions PLEASE DO NOT USE THIS FORM if you are a participating provider with Kaiser Permanente and are making demographic changes or adding providers to your practice. Please contact our Provider Relations Department at for assistance. Attached are application forms to be completed and submitted for consideration into our network of providers. Please complete appropriate application form and submit to the address below. Practitioner Application (Pages 1 and 2) should be used by providers such as physicians, behavioral health providers, physical therapists, and other professionals. Facility / Institutional Application should be used for services such as home health care, hospitals, nursing homes, ambulatory surgery centers, durable medical equipment and other facilities. It is important that you clearly describe the services you offer so we can best assess our need for your services. Your completed application must also include the attached Disclosure of Ownership and Control Information Form. We welcome any attachments, brochures, or descriptions you may choose to include. Incomplete or illegible applications will be automatically denied and returned to you within ten (10) days of receipt. Should you have any questions regarding this application, please contact Provider Relations at PLEASE RETURN YOUR COMPLETED APPLICATION TO: Attention: Interested Provider Coordinator 2101 East Jefferson Street, 2E Rockville, MD Fax Number: (301) address: Provider.Relations@KP.Org Kaiser Permanente will notify you of our decision in writing within 30 days of our receipt of your application. DISCLAIMER: All information will be assessed against Kaiser Permanente s network needs. Submission of an application does not constitute any obligation on the part of KFHP-MAS, MAPMG, or any other related Kaiser Permanente entities to enter into a contractual relationship with you. 01/11/2013

2 Group/Practice name: Fed Tax I.D. Number: Provider Application for Participation Practitioner Information Page 1 For office use only Date Application Received: Are you currently participating with Kaiser Permanente under another practice? If so, please provide practice name and Federal Tax I.D. Number Contact name: Contact street address: City: State: Zip: Phone: Fax: Office locations: (Attach additional page if necessary.) Street address City State Zip (1) Primary: (2) Other: (3) Practitioner Specialty (ex: Cardiology, Family Practice, OB/GYN, General Surgery, etc.): (1) (2) (3) For non-mds and/or subspecialties: please provide a detailed description of the services you provide including age range served and area(s) of expertise. Attach additional page if necessary. Foreign language(s) that the Group/Practice are able to treat patients in: (1) (2) (3) Does this group practice exclusively in a hospital setting? Hospital(s) where providers have admitting/staff privileges: (1) (2) (3) Does this Group/Practice: Yes No Currently offer 24/7 coverage? (include all covering providers on Provider Information page) Yes No Maintain general liability insurance at the minimal limits of $1,000,000/$3,000,000? Yes No Have a physical address and location outside your home? Yes No Participate with Medicare? Have Medicare Number? Yes No Yes No Participate with Medicaid? Have Medicaid Number? Yes No Yes No Agree to facilitate all necessary credentialing activities?

3 Use this page for Additional Practice Information

4 Provider Application for Participation Practitioner Information Page 2 Please type or print clearly. All information is REQUIRED and must include covering physicians. Provider Name and Title Specialty SSN Medicare Number Medicaid Number EPSDT* Certified (Y or N) CAQH** Number Hospital Privileges at Hospital Based? *EPSDT (Maryland Healthy Kids/ Early Periodic Screening, Diagnosis and Treatment Program) Visit **CAQH (Council for Affordable Quality HealthCare) is a universal national data source for standardizing the provider Credentialing application process. Visit ATTN: Please ensure provider information is CURRENT and UPDATED on CAQH

5 DISCLOSURE OF OWNERSHIP & CONTROL INFORMATION This section must be completed by an authorized representative of the participating provider practitioner, group, or facility. An authorized representative is defined as an individual with designated authority to act on behalf of the individual, group of practitioners, or disclosing entity. If not a solo practitioner, then the authorized representative must be a partner, president, or secretary of the group of practitioners. 1. Ownership and Control Information for Disclosing Entity, 42 C.F.R List any individual who has any ownership or controlling interest in this provider entity or in any subcontractor. List the name, title, (i.e. CEO, President), address, Tax ID (TIN) of any organization, corporation, or entity having any ownership or controlling interest in this provider entity. The ownership or controlling interest is an ownership interest of 5% or more in this provider entity. 2. Relationships List those individuals named in Question 1 that are related to each other (spouse, parent, child, or sibling). Include name, relationship, and SSN. 3. Subcontractor List any individual with an ownership or control interest in any subcontractor that the disclosing entity has direct or indirect ownership of 5% or more. 4. Other Disclosing Entity List the name, address, and TIN of any other disclosing entity other than subcontractor in which a person, with an ownership or controlling interest in this disclosing entity, has an ownership or control interest of at least 5% or more.

6 5. Criminal Offenses Has any individual or organization listed in Questions 1, 2, 3 and 4 ever been convicted or assessed fines or penalties for any health related crimes or misconduct, or excluded from any Federal or State health care program due to fraud, obstruction of an investigation, a controlled substance violation or any other crime or misconduct? If your answer to this question is YES, please provide the name, address, SSN/TIN and percentage of ownership for individual(s) or Organization(s). Yes No 6. Has any individual or contractor connected with your practice been convicted or assessed fines or penalties for any health related crimes or misconduct, or excluded from any Federal or State health care program due to fraud, obstruction of an investigation, a controlled substance violation or any other crime or misconduct? If your answer to this question is YES please provide the name, address, and SSN/TIN for individual(s) or contractor(s). Yes No 7. Has the applicant ever had any adverse legal actions imposed by Medicare, Medicaid, or any other Federal or State agency or program, or any licensing or certification agency? If yes, please provide a copy of relevant final disposition Yes No