Enrollment Attestation Packet

Transcription

1 Enrollment Attestation Packet The following paperwork is required for enrollment for the contracted health plans that UPMC Pinnacle participates with. Please sign in either BLUE or BLACK Ink, as indicated at the start of each document set. Please do NOT date the pages. Signatures required only. Undated attestations will allow us to fill in the date when submitting enrollment forms, which may vary depending on the health plan requirements and/or start dates. Some plans will only allow application submission 30 days in advance. Answer all professional questions YES OR NO and include documentation for any YES responses you provide. The Enrollment Attestations MUST be submitted via FedEx, US Postal Mail or UPS. The documents cannot be accepted via . Many of the insurance companies require original signatures. All enrollment materials should be mailed to: UPMC Pinnacle Physician & Practitioner Services Department Attn: Heather Johnson, System Director Medical Staff and Credentialing of Physician & Practitioner Services 409 South Second Street Suite 2F Harrisburg, PA Phone: Please do not hesitate to contact me if you have any additional questions.

2 Access to Provider Web-Based Applications for Payor Credentialing and Enrollment UPMC Pinnacle contracts and participates with a variety of payors/insurances requiring the use of multiple web-based applications. These web-based applications include: CAQH ProView National Plan & Provider Enumeration System (NPPES)/National Provider Identifier (NPI) PECOS Medicare Enrollment PROMISe Pennsylvania Department of Human Services Medical Assistance Authorized personnel within the health system may establish and maintain information within these web-based applications for the purposes of payor enrollment and credentialing, re-credentialing, revalidation, and billing as it pertains to UPMC Pinnacle. Information for organizations not under the UPMC Pinnacle umbrella will not be maintained or corrected by personnel within the health system without permission from the provider. Establishing provider profiles within the above mentioned web-based applications requires login set up, with usernames, passwords, and security questions chosen by authorized personnel within the health system. Login information will be stored in a secure database accessible only by authorized personnel. If a provider needs login information to an above mentioned web-based application a request can be sent to hjohnson@pinnaclehealth.org. Please allow up to three business days for a response. Maintaining provider profiles previously established within the above mentioned web-based applications will require login information to be entered by providers into the secure database or released in a secure manner to authorized personnel for entry into the database. Provider Authorization By signing below you acknowledge that you have read the above information and grant permission to those authorized personnel within the health system to establish and/or maintain the above mentioned web-based applications. You also acknowledge that you will not change login information without notifying authorized personnel in a timely and appropriate manner. You will not make any changes to information that may pertain to UPMC Pinnacle or the health system s authorized personnel receiving updates, cause changes to credentialing/enrollment with contracted payors, or interfere with reimbursement. Provider Name (Printed) Provider Signature Date If you have any questions concerning this form please contact Heather Johnson, System Director Medical Staff and Credentialing of Physician & Practitioner Services, at

3 IV. CONFIDENTIAL INFORMATION IF YOU HAVE ANY YES ANSWERS TO ANY QUESTIONS IN THE SECTIONS BELOW AND THOSE ON PAGE 9, REFERENCE THE QUESTIONS ON A SEPARATE SHEET, GIVE FULL DETAILS AND ATTACH. Have any of the following at any time been, or are they currently in the process of being denied, revoked, not renewed, suspended, limited, restricted, placed on probation, or placed under other disciplinary action, either voluntarily or involuntarily in this or any other state? Medical or professional license DEA or CDS/BNDD registration Hospital medical staff membership Clinical privileges or other rights on any hospital medical staff Employment by any hospital, institution, or the military Professional society memberships Participation in any private, federal, or state health insurance program (i.e., Medicare, CHAMPUS, Medicaid) Participation in an HMO, PPO, or any other managed care organization Board Certification At any time, have you ever been Convicted of a criminal offense Convicted of a felony Convicted of a misdemeanor relating to a health profession, or received probation without a verdict, disposition in lieu of trial, or an accelerated rehabilitation disposition in the disposition of felony charges in any state, territory or country Have you ever at any time or are you currently Under indictment for any crime The subject of an investigation by any private, federal or state health insurance program or state licensing board Under investigation by any state licensing board or federal agency The subject of any adverse action reports to a state or federal databank Have you ever either voluntarily or involuntarily Withdrawn your application for medical staff membership at any facility Withdrawn your request for any clinical privileges at any facility Health Status Are you able to perform the professional duties of the position with or without reasonable accommodation? (A NO answer to this question does require additional documentation) Are you currently using illegal substances or illegally using substances? Applicant s Name PA Standard Application Rev 12/06 Page 8 of 10

4 IF YOU ANSWER YES TO ANY OF THE QUESTIONS ABOVE, PROVIDE THE FOLLOWING INFORMATION FOR EACH CASE/SITUATION Date of occurrence of alleged malpractice Plaintiff name Name of the insurance carrier involved Status of the case Your status is/was in this case Primary Defendant CoDefendant Pending If pending, list carrier Found for plaintiff Found for defendant Dismissed / dropped Settled If settled, give the amount Professional relationship to patient Alleged harm to patient Circumstances of patient's illness Any other pertinent details REQUIRED COPIES REFER TO INSTRUCTIONS FROM EACH MANAGED CARE ORGANIZATION FOR DOCUMENTS REQUIRED FOR CREDENTIALS THAT ARE IN ADDITION TO THE INFORMATION YOU ATTACH TO PROPERLY RESPOND TO QUESTIONS ON THIS APPLICATION. By signing this application, I hereby certify that all information contained in this application is true, correct and complete in all respects and agree to promptly notify the "recipient" immediately if there are any changes in the information provided. Applicant's Signature Date Applicant's Name PA Standard Application Rev 12/06 Page 10 of 10

5 NPI # NPPES LOG ON ID: PASSWORD: CAQH # LOG ON ID: PASSWORD: Birthplace (City, State and Country if not US)

6 Credentialing Heather Johnson Provider Centers for Medicare & Medicaid Services (CMS) EHR Incentive Program Questionnaire The following information is needed for IT to properly setup the new provider to participate in the EHR Incentive Programs. Provider Name: Clinical Title: (ex: MD, DO, PA, NP, etc.) NPI: Date of Hire: Specialty: (ex: Orthopedic, Neurology, Family Med, etc.) Department Name: Location Name: 1) Have you previously participated in Meaningful Use? YES NO - If yes, who was your previous employer when participating? - If yes, what Stage and Year have you completed? (if the provider does not know, the UPMC Pinnacle CMS Delegated Official can look up this information) - If yes, have you failed any years and what year? (if the provider does not know, the UPMC Pinnacle CMS Delegated Official can look up this information) - If yes, is the provider considered to be primarily Office Based or Hospital Based? 2) Please indicate the Providers PECOS User Id and Password. - User Id Password This information will remain confidential. The user id and password are needed to allow the UPMC Pinnacle CMS Delegated Official to be assigned to the provider in order to perform the CMS attestation for the EHR Incentive program. Please return this completed form via to: Andrew Brown at abrown@pinnaclehealth.org

7 Be sure to complete all questions.* (Please provide a detailed description of all positive responses in this section.) PROFESSIONAL QUESTIONS A. Have you ever had any negative action taken in connection with your license, including, but not limited, to refusal, suspension, revocation, probation reprimand, censure or restriction in any way by any state or jurisdictional board? B. Have you ever been censured by a medical society or other professional society or other professional board or association? C. Have you ever had your Drug Enforcement Administration number (DEA #) restricted, suspended, revoked or otherwise limited or DEA license application refused? D. Have you ever had an agreement with Medicare or Medicaid that was restricted, probational, suspended, excluded or terminated? E. Have you ever been required or agreed to pay civil monetary penalties under Medicare or Medicaid? F. Have you ever been convicted of a criminal offense other than a minor traffic violation? G. Has any hospital or facility ever taken any action regarding your privileges, including, but not limited, to suspension, restriction, denial or revocation? H. Have you ever voluntarily resigned privileges in lieu of disciplinary action? I. Has there been, within the last five years, more than one malpractice judgment found against you or malpractice settlement made, with or without prejudice, in excess of fifty thousand ($50,000) dollars? NA J. Do you have an impairment which, even with reasonable accommodation would interfere with your ability to provide care according to accepted standards of professional performance, or would pose a threat to patient health and safety? K. Are you now or have you ever been an active or habitual user of any mind or mood altering substance, including, but not limited, to alcohol, narcotics, barbiturates, hypnotics, amphetamines, cocaine, benzodiazepines, or other controlled or illegal substances? L. Has your participation in any insurance carrier sponsored program been suspended or revoked? ATTESTATION / RELEASE I hereby submit this application for participation in the Private Healthcare Systems, Inc. ( PHCS ) Network. I understand that this application will be reviewed based on the information I have provided herein. I hereby certify that the information contained and enclosed with this form is complete, accurate and true, and that information found to be false could result in denial or subsequent termination of my participation in the PHCS Network. To assist PHCS and/or its Credentials Verification Organization (CVO) in evaluating my application, I authorize any hospital, group practice, other clinical employer, professional society, malpractice carrier or other agency or organization with information regarding my professional credentials to release, furnish copies, or give details of my professional credentials, qualifications and hospital records related to my privileges, qualifications, type of clinical practice and competence, including my moral and ethical qualifications. I hereby release from liability any and all individuals and organizations who, in good faith and without malice, provide information to PHCS for the purposes of evaluating this application, and release PHCS from liability for its use of the information it gathers in the application process. A photocopy of this permission will be as valid as the original. X Signature of Provider Name (please type or print) Date (mm,dd,yy) NOTE: Signature and date on this application MUST be within 30 days of submission to PHCS. 1. Completed and signed Preferred Group Practitioner Application. 2. Copy of current insurance certificate which includes Professional and Comprehensive General Liability. REMEMBER TO ENCLOSE 3. Copy of current DEA and license certificate(s). 4. Copy of W-9 Form. Please note that TIN Name must match the name on your W-9. If not, a letter giving you permission from the TIN owner to use the TIN Number must accompany this application. 5. Copy of Curriculum Vitae. 6. Detailed explanation and documentation for any affirmative responses to Professional Questions or Employment History Gaps six (6) months or greater. Don t Forget To Sign and date the Preferred Group Practitioner Application Keep a photocopy of the Preferred Group Practitioner Application for your records. NOTE: We cannot process an incomplete submission. * Information will be kept confidential to the extent permitted by law. Page 4 of 4 Questions? Call PRVP083 (1/1/06)

8 Affirmation of Medical Practice Statement By signing this affirmation, I declare my desire to join or remain a provider of Highmark Health Services and its affiliates commercial and Medicare Advantage networks. I understand that the information herein will be used by Highmark Health Services, Highmark West Virginia Inc. ("Highmark WV"), Highmark Blue Cross Blue Shield Delaware Inc. ( Highmark DE ) and/or Highmark Health Insurance Company ("HHIC") in making decisions about my participation in the networks. I understand that credentialing will not be required as a condition of my becoming or remaining a party to one or more of the Highmark Health Services, Highmark WV, Highmark DE and/or HHIC provider agreements, provided that (1) the services I provide to members serviced by the networks are delivered exclusively in the acute care hospital setting; (2) I provide medical care for such members only when they receive services in a Highmark Health Services, Highmark WV, Highmark DE and/or HHIC participating acute care hospital; (3) I possess a current license in good standing in the state in which medical services are provided; (4) I have current active malpractice insurance that meets or exceeds the Highmark Health Services requirements; (5) I actively participate with Medicare/Medicaid and have never been debarred from, or excluded from participation in, any Medicare/Medicaid government program; and (6) I am a member of the practice listed below. By signing below, I am confirming that conditions (1) through (6) in the above paragraph are true and accurate statements. I also agree to supply a certificate of malpractice insurance. I will be providing services to members serviced by the networks in the following Highmark Health Services, Highmark WV, Highmark DE and/or HHIC participating acute care hospital(s): Please indicate your specialty (*required): I understand that if I begin to provide service to members outside of a Highmark Health Services, Highmark WV and/or HHIC participating acute care hospital, I will have to be credentialed by Highmark Health Services, Highmark WV and/or HHIC as a condition of the applicable provider agreements and participation in the applicable networks. Practice Name: Type 2/Group National Provider Identifier (NPI): Highmark Health Services Group Provider Number: Practice Name: Type 2/Group NPI: Highmark Health Services Group Provider Number: Practice Name: Type 2/Group NPI: Highmark Health Services Group Provider Number: Practitioner Name: Medicare Number: Type 1/Individual NPI: Highmark Health Services Individual Provider Number: Physician Signature: Date: 282 (R08-13)

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11 CAQH ProView - Disclosure Page 1 of 5 3/9/2016 HELP CONTACT CAQH SIGN OUT CAQH ProView Status Updates Suzanne Horton CAQH ID# HOME PROFILE DATA DOCUMENTS REVIEW ATTEST Provider Status: First Provider Contact (3/9/2016) Profile Data: Incomplete Documents: Incomplete Save PERSONAL INFORMATION PROFESSIONAL IDS CAQH DISCLOSURE OF OWNERSHIP EDUCATION PROFESSIONAL TRAINING SPECIALTIES PRACTICE LOCATIONS HOSPITAL AFFILIATIONS CREDENTIALING CONTACTS DISCLOSURE If you do not believe a question is applicable to you, you should answer the question. You are required to enter malpractice case history information if applicable. Click the Add button to enter a malpractice case history record. Licensure PROFESSIONAL LIABILITY INSURANCE EMPLOYMENT INFORMATION PROFESSIONAL REFERENCES DISCLOSURE 1. Has your license, registration or certification to practice in your profession ever been voluntarily or involuntrarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or certification board? * AUTHORIZE 2. Has there been any challenge to your licensure, registration or certification? * Hospital Privileges and Other Affiliations 3. Have your clinical privileges or medical staff membership at any hospital or healthcare institution, voluntarily or involuntarily, ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical record when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board? * 4. Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation? * 5. Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)? *

12 CAQH ProView - Disclosure Page 2 of 5 3/9/2016 Education, Training and Board Certification 6. Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign? * 7. Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program? * 8. Have any of your board certifications or eligibility ever been revoked? * 9. Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation? * DEA or CDS 10. Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s) or authorization(s) ever been challenged, denied, suspended, revoked, restricted, denied renewal, or voluntarily or involuntarily relinquished? * Medicare, Medicaid or other Governmental Program Participation 11. Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs? * Other Sanctions or Investigations

13 CAQH ProView - Disclosure Page 3 of 5 3/9/ Are you currently the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program or a defendant in any civil action that is reasonably related to your qualifications, competence, functions, or duties as a medical professional for alleged fraud, an act of violence, child abuse or a sexual offence or sexual misconduct? * 13. To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank? * 14. Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)? * 15. Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted, disciplined or resigned in exchange for no investigation or adverse action within the last ten years for sexual harassment or other illegal misconduct? * 16. Are you currently being investigated or have you ever been sanctioned, reprimanded, or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation or in exchange for no investigation by a hospital or healthcare facility of any military agency? * Professional Liability Insurance Information and Claims History 17. Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history? * 18. Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional liability insurance carrier, based on your individual liability history? * Malpractice Claims History 19. Have you ever had any professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past 10 years? If yes, provide information for each case. *

14 CAQH ProView - Disclosure Page 4 of 5 3/9/2016 Criminal/Civil History* 20. Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony? * 21. In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offence or sexual misconduct? * 22. Have you ever been court-martialed for actions related to your duties as a medical professional? * Ability to Perform Job 23. Are you currently engaged in the illegal use of drugs? (Currently means sufficiently recent to justify a reasonable belief that the use of drug may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. Illegal use of drugs refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C It does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the controlled Substances Act or other provision of Federal law. The term does include, however, the unlawful use of prescription controlled substances.) * 24. Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety? * 25. Do you have any reason to believe that you would pose a risk to the safety or well being of your patients? * 26. Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonable accommodation? *

15 CAQH ProView - Disclosure Page 5 of 5 3/9/2016 Save and Go Back Save Save & Continue PROD (.15) TERMS OF SERVICE PRIVACY CAQH.ORG 2015 CAQH. All rights reserved.

16 Standard Authorization, Attestation and Release (t for Use for Employment Purposes) 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 Provider 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 do 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 agent(s); 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, and the Health Care Integrity and Protection Data Bank, to release to the Entity and/or 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 third 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 Information" 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 retains 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 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 10 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. 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 have access to the bylaws of applicable medical staff organizations and agree to abide by these bylaws, 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. Signature* Name (print)* M M D D Y Y Y Y DATE SIGNED*

17 22. Have you ever: A. Had clinical privileges or hospital privileges denied, suspended, restricted, revoked, or not renewed; either voluntarily or involuntarily for an agreed to definite or indefinite period of time? If, please attach details B. Had any judgments entered against you or settlements been agreed to in any professional liability cases? If, please attach details C. Are there any professional liability lawsuits pending against you at the present time? If, please attach details D. Do you have physical or mental health condition(s) which in any way impairs your ability to practice your profession, with or without accommodations? If, please attach details E. Do you have any physical or mental health condition(s) which in any way poses a risk of harm to your patients? If, please attach details F. Are you currently using, or have you used in the past five years, drugs or any other chemical substance that has or may impair your ability to practice your profession? If, please attach details If you answered to any of the questions above, you MUST provide a detailed statement of the circumstances relating to the YES response as well as an explanation as to why you think this response should not result in a denial of your enrollment to participate in MA Program. You may also submit statements from professional associates or peer review bodies. Include in your statement the following information as it applies to each situation: Name and title of the individual applicant Date of professional malpractice action Description of professional malpractice action Explanation of any physical or mental health condition(s) that impairs your ability to practice your profession Explanation of any physical or mental health condition(s) that poses a risk of harm to your patients Explanation of drug or chemical substance use 01/17/

18 23. Have you or anyone in your employ ever: A. Been terminated, excluded, precluded, suspended, debarred from or had your participation in any federal or state health care program or hospital privileges limited in any way, including voluntary withdrawal from a program for an agreed to definite or indefinite period of time? If, please attach details B. Been the subject of a disciplinary proceeding by any licensing or certifying agency, had your license limited in any way, or surrendered a license in anticipation of or after the commencement of a formal disciplinary proceeding before a licensing or certifying authority (e.g., license revocations, suspensions, or other loss of license or any limitation on the right to apply for or renew license or surrender of a license related to a formal disciplinary proceeding)? If, please attach details C. Had a controlled drug license withdrawn? If, please attach details D. Been convicted of a criminal offense related to Medicare or Medicaid, or a state health care program? If, please attach details E. Been convicted of a criminal offense relating to the unlawful manufacture, distribution, prescription or dispensing of a controlled substance? If, please attach details F. Been convicted of interference with or obstruction of any investigation? If, please attach details G. In connection with the delivery of a health care item or service, or with respect to any act or omission in a heath care program, been convicted of any criminal offense relating to neglect or abuse of patients or fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct? If, please attach details H. Been in default on repayments of scholarship obligations or loans in connection with your education as a health professional? If, please attach details I. Been subject to a civil penalty or assessment for any act or omission related to Medicare, Medicaid, or a state health care program? If, please attach details ** In addition to answering the above questions you are REQUIRED to complete Attachment 3 PROVIDER DISCLOSURE STATEMENT. 01/17/

19 Provider Information Form (PIF) This form should be completed electronically or legibly printed in blue or black ink. All fields are required, unless otherwise noted. te: Behavioral health providers should not complete this form. Contact MHN at or visit Please read the Conditions of Participation listed on the Credentialing for TRICARE Network Provider page at before completing this form. N/A I agree to bill Medicare for all Medicare-eligible patients. Disqualifying Questions (te: A yes answer disqualifies you from participation) Provider Information Form (PIF) 1. I am currently an active duty service member or an employee (including part-time or intermittent) appointed in the civil service of the United States Government. 2. I have a felony conviction. 3. I have a current Medicare/Medicaid sanction. 4. I have a professional license(s) revoked, suspended, limited or have been placed on probation. Identifying Information (Must match CAQH application) Last Name First Name MI Title/Degree DOB Male Female Individual Medicare ID Number SSN ( dashes) Individual NPI (Type I) ( dashes) CAQH ID (If applicable) Primary Directory Specialty Secondary Directory Specialty (If applicable) Address Will you accept Civilian Health and Medical Program of the Department of Veterans Affairs patients? Will you accept assignment of Department of Veterans Affairs patients? Are you participating as a primary care manager (PCM), and/or specialist (Spec), or as a hospital-based specialist? PCM Spec Hospital-based specialist Are you accepting new patients? Page 1 of 3 HF0314x070x0314 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last updated 3/24/14

20 Credentials Attestation, Authorization and Release I acknowledge and agree that Health Net Federal Services, LLC (Health Net) has a valid interest and legal requirement to obtain and verify information concerning my professional competence, therefore: 1. I authorize Health Net and/or any entity with which it may contract for verification services to consult with hospital administrators, physicians, malpractice carriers and other persons or entities to obtain and verify information concerning my professional competence, character, moral and ethical qualifications. I release Health Net and its employees, managers, agents and consulting committees form any and all liability for their acts performed in good faith and without malice in obtaining, verifying and evaluating such information. 2. I consent to and authorize the release by any person or entity to Health Net of all information and documents that may be relevant to an evaluation of my professional competence, character, morality and ethical qualifications, including any information or material relating to any disciplinary or criminal action, professional competence, suspension or curtailment of medical or surgical privileges (including malpractice claims and/or coverage). I hereby release any such person or entity providing such information from any and all liability for doing so. If I have contracted with a medical group, Individual Physician Association or similar entity as a participating provider with Health Net or such other health plans, they also may receive the credentialing information or quality assurance data relating to me. 3. I understand that I have the burden and legal responsibility of providing adequate information to Health Net to demonstrate my professional competence, character, moral ethics and other qualifications. 4. I attest to the fact the information submitted by me in this application is true, correct and complete to the best of my knowledge and belief. I fully understand that any significant misstatement in, or omission from, this application may constitute cause for denial of participation or cause for summary dismissal from the Health Net Provider Network, or be subject to applicable state or federal penalties for perjury. 5. If any material changes occur affecting my professional status, I agree to notify Health Net within five days, as per Section 2.16 of the Professional Provider Agreement. 6. I have attached my Professional Liability Insurance (PLI) with this form, or I have posted a current copy of my PLI on CAQH, which expires: te: Application will be returned if there is no current copy of PLI on CAQH. Date of Professional Liability Insurance Expiration Provider Name (Type or use block print) Provider Signature Date te: Must be signed and dated within 30 days of submittal. Print Form Page 3 of 3 Last updated 3/24/14

21 Prefers signature in BLUE Ink, Must submit original signature (no copies or faxes accepted) Reminder: Please do not date Medicare enrollment vitas Solutions CMS contractor (following signature pages 2 copies of each) CMS-855I - Certification Statement CMS-855R - Authorization Statements

22 SECTION 15: CERTIFICATION STATEMENT (Continued) First Name Middle Initial Last Name M.D., D.O., etc. Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.) Date Signed (mm/dd/yyyy) All signatures must be original and signed in ink (blue ink preferred). Applications with signatures deemed not original will not be processed. Stamped, faxed or copied signatures will not be accepted. SECTION 16: FOR FUTURE USE (THIS SECTION NOT APPLICABLE) SECTION 17: SUPPORTING DOCUMENTS This section lists the documents that, if applicable, must be submitted with this enrollment application. For changes, only submit documents that are applicable to the change requested. The fee-for-service contractor may request, at any time during the enrollment process, documentation to support or validate information reported on the application. In addition, the Medicare fee-for-service contractor may also request documents from you, other than those identified in this section 17, as are necessary to bill Medicare. MANDATORY FOR ALL PROVIDER/SUPPLIER TYPES NOTE: NOTE: this application or enrolling as a sole proprie MANDATORY, IF APPLICABLE ˇ ˇ NOTE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to 4 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application processing. CMS-855I (07/11) 26

23 SECTION 15: CERTIFICATION STATEMENT (Continued) First Name Middle Initial Last Name M.D., D.O., etc. Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.) Date Signed (mm/dd/yyyy) All signatures must be original and signed in ink (blue ink preferred). Applications with signatures deemed not original will not be processed. Stamped, faxed or copied signatures will not be accepted. SECTION 16: FOR FUTURE USE (THIS SECTION NOT APPLICABLE) SECTION 17: SUPPORTING DOCUMENTS This section lists the documents that, if applicable, must be submitted with this enrollment application. For changes, only submit documents that are applicable to the change requested. The fee-for-service contractor may request, at any time during the enrollment process, documentation to support or validate information reported on the application. In addition, the Medicare fee-for-service contractor may also request documents from you, other than those identified in this section 17, as are necessary to bill Medicare. MANDATORY FOR ALL PROVIDER/SUPPLIER TYPES NOTE: NOTE: this application or enrolling as a sole proprie MANDATORY, IF APPLICABLE ˇ ˇ NOTE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to 4 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application processing. CMS-855I (07/11) 26

24 SECTION 5: CONTACT PERSON INFORMATiON (Optional) If questions arise during the processing of this reassignment, the designated MAC will contact the individual indicated below. If a contact person is not furnished, the MAC will contact the individual practitioner is Section 3. First Name Middle Initial Last Name Jr., Sr., M.D., etc. Contact Person Address Line 1 (Street Name And Number) Contact Person Address Line 2 (Suite, Room, Apt. #, etc.) City ff own State ZIP Code +4 Telephone Number Fax Number (if applicable) Address (if applicable) Relationship or Affiliation to Individual or Organization/Group (Spouse, Secretary, Attorney, Billing Agent, etc.) NOTE: The Contact Person listed in this section will only be authorized to discuss issues concerning this reassignment. The designated MAC will not discuss any other Medicare issues about the organization/group or individual practitioner beyond this reassignment application with the above Contact Person. SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES Title XVIII of the Social Security Act prohibits payment for services provided by an individual practitioner to be paid to another individual or organization/group unless the individual practitioner who provided the services specifically authorizes another individual or organization/group to receive said payments in accordance with 42 CFR and 42 CFR All individual practitioners who allow another individual or organization/ group to receive payment for their services must sign the Reassignment of Medicare Benefits Statement below. By signing this Reassignment of Medicare Benefits Statement, you are authorizing the organization/group or individual identified in Section 2 to receive Medicare payments on your behalf. The signature(s) below authorize the reassignment of benefits, or the termination of a reassignment of benefits, between the individual practitioner shown in Section 3 and the organization/group shown in Section 2. The employment of, or contract between, the individual practitioner and organization/group or individual must be in compliance with CMS regulations and applicable Medicare program safeguard standards described in 42 CFR These signatures also serve as an attestation and acknowledgment to the compliance with all laws and regulations pertaining to the reassignment of Medicare benefits. A. Individual Practitioner Certification Statement and Signature Under penalty of perjury, I, the undersigned, certify that the above information is true, accurate and complete. I understand that any misrepresentation or concealment of any information requested in this application may subject me to liability under civil and criminal laws. Individual Practitioner First Name (Print) Middle Initial Last Name (Print) Jr., Sr., M.D., etc. Individual Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.) Date Signed (mmlddlyyyy) B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature Under penalty of perjury, I, the undersigned, certify that the above information is true, accurate and complete. I understand that any misrepresentation or concealment of any information requested in this application may subject me and/or the organization/group to liability under civil and criminal laws. Delegated or Authorized Official's First Name (Print) Middle Initial Last Name (Print) Jr., Sr., M.D., etc. Delegated or Authorized Official's Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.) Date Signed (mmlddlyyyy) All signatures must be original and signed in blue ink. Applications with signatures deemed not original or not dated will not be processed. Stamped, faxed or copied signatures will not be accepted. CMS-855R (04/16) 3

25 SECTION 5: CONTACT PERSON INFORMATION (Optional) If questions arise during the processing of this reassignment, the designated MAC will contact the individual indicated below. If a contact person is not furnished, the MAC will contact the individual practitioner is Section 3. First Name Middle Initial Last Name Jr., Sr., M.D., etc. Contact Person Address Line 1 (Street Name And Number) Contact Person Address Line 2 (Suite, Room, Apt. #, etc.) City/Town State ZIP Code +4 Telephone Number Fax Number (if applicable) Address (if applicable) Relationship or Affiliation to Individual or Organization/Group (Spouse, Secretary, Attorney, Billing Agent, etc.) NOTE: The Contact Person listed in this section will only be authorized to discuss issues concerning this reassignment. The designated MAC will not discuss any other Medicare issues about the organization/group or individual practitioner beyond this reassignment application with the above Contact Person. SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES Title XVIII of the Social Security Act prohibits payment for services provided by an individual practitioner to be paid to another individual or organization/group unless the individual practitioner who provided the services specifically authorizes another individual or organization/group to receive said payments in accordance with 42 CFR and 42 CFR All individual practitioners who allow another individual or organization/ group to receive payment for their services must sign the Reassignment of Medicare Benefits Statement below. By signing this Reassignment of Medicare Benefits Statement, you are authorizing the organization/group or individual identified in Section 2 to receive Medicare payments on your behalf. The signature(s) below authorize the reassignment of benefits, or the termination of a reassignment of benefits, between the individual practitioner shown in Section 3 and the organization/group shown in Section 2. The employment of, or contract between, the individual practitioner and organization/group or individual must be in compliance with CMS regulations and applicable Medicare program safeguard standards described in 42 CFR These signatures also serve as an attestation and acknowledgment to the compliance with all laws and regulations pertaining to the reassignment of Medicare benefits. A. Individual Practitioner Certification Statement and Signature Under penalty of perjury, I, the undersigned, certify that the above information is true, accurate and complete. I understand that any misrepresentation or concealment of any information requested in this application may subject me to liability under civil and criminal laws. Individual Practitioner First Name (Print) Middle Initial Last Name (Print) Jr., Sr., M.D., etc. Individual Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.) Date Signed (mm/ddlyyw) B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature Under penalty of perjury, I, the undersigned, certify that the above information is true, accurate and complete. I understand that any misrepresentation or concealment of any information requested in this application may subject me and/or the organization/group to liability under civil and criminal laws. Delegated or Authorized Official's First Name (Print) Middle Initial Last Name (Print) Jr., Sr., M.D., etc. Delegated or Authorized Official's Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.) Date Signed (mmlddlyyyy) All signatures must be original and signed in blue ink. Applications with signatures deemed not original or not dated will not be processed. Stamped, faxed or copied signatures will not be accepted. CMS-855R (04/16) 3

26 Hospital-based Practitioner Profile Practitioner Specialty Board Certified Board Eligible r Anesthesiology r r r r r Emergency Medicine r r r r r Neonatology r r r r r Pathology r r r r r Radiology r r r r r Hospitalist r r r r r Other (please specify) r r r r Are you pursuing Board Certification in the Specialty for which you are applying? r r If yes, when is your date planned? Hospital Affiliation(s) Do you practice exclusively in the hospital setting? r r If no, will members be directly referred to this practitioner? r r Does practitioner practice in an office setting outside of the main hospital? r r Does practitioner have scheduled office hours for members? r r Does practitioner practice exclusively within a free standing facility providing care for members only as a result of members being directed to the facility? r r Practitioner Information Individual NPI Medical License # Name (Last Name) (First Name) (Middle) (Title) Social Security # Date of Birth / / Gender Ethnicity (optional) Medicare # DEA # Languages Medicaid # If you do not have a Medicaid #, have you applied for one? r r If yes, when did you apply? Internship/Residency Institution Type of Training City State Country Specialty Program Completed: r r Date of Entry / / Date of Completion / / If not completed, please explain Practice Information Practice Name Practice Address City State Zip Phone # ( ) Fax # ( ) Revision Date: July, 2015 Page 1 of 2