State of Utah ) County of _Salt Lake ) LIMITED POWER OF ATTORNEY I, (print provider name), being of sound mind, willfully and voluntarily appoint the University of Utah, a body politic and corporate of the State of Utah, through its Graduate Medical Education Office (GME) and Provider Enrollment team, to perform in my name and stead the following acts as my attorney-in-fact, which are hereby limited: Complete and sign CMS Enrollment Applications: CMS-855A,855I, 855B and 855O Complete and sign CMS Revalidation Form: CMS-855B, 855I and 855O Complete and sign Reassignment of Medicare Benefits Form: CMS-855R E-sign Electronic CMS Enrollment Application in PECOS E-sign Electronic CMS Revalidation Form in PECOS Sign/E-sign Medicaid Enrollment Applications Medicaid Re-Enrollment Application Medicaid Contracts and Agreements Medicaid Enrollment Change Forms Dental Credentialing Applications Vision Credentialing Applications Tricare/Department of Workers Compensation/Department of Labor & Industries Commercial Non-Delegated Credentialing and Re-Credentialing Applications The authority granted herein shall include such incidental acts as are reasonably required to carry out and perform the specific authorities granted herein. The rights, powers, and authority granted by this Special Power of Attorney shall commence as of the date of my signature below. This Special Power of Attorney may be revoked by me at any time, and shall automatically be revoked upon my death or termination of my employment with the University of Utah, provided any person relying on this power of attorney shall have full rights to accept and rely upon the authority of my attorney-in-fact until such time as they are in receipt of actual notice of revocation. DATED as of this day of, 20. Print Name Signature
Medicaid Provider Application Questions Name Please use the drop down box to answer Yes or No. If yes, please write a short response in the box provided. Section 4: Managing Employee/ Agent List 1. Been convicted of a healthcare related felony or any other criminal offense, State, or Federal, under this name or any other name in any state or U.S. Territory, regardless of a post motion, a plea of guilty or nolo contendere or participation in a First Offense pardon program? 2. Had any disciplinary action taken against any professional license or certificate held in any state or U.S. Territory, including disciplinary action, board consent order, suspension, revocation, or voluntary surrender of a license or certification? 3. Been denied enrollment, suspended, terminated from participation, excluded, or voluntarily withdrawn to avoid disciplinary action from Medicaid or other healthcare program(s) in any state or U.S. Territory, or employed by a corporation, entity/business, or professional association that has ever been denied enrollment, suspended, terminated, excluded, or voluntarily withdrawn to avoid disciplinary action from Medicaid or other healthcare program(s) in any State or U.S. Territory? 4. Are you currently or have you ever been terminated from Medicare? Section 17: Complete Enrollment Checklist 1. Have you or any employee ever had an Assessment taken 2. Have you or any employee ever had an Administrative Sanction taken 3. Have you or any employee ever had a Suspension or Payment taken 4. Have you or any employee ever had a Restitution Order taken against you? 5. Have you or any employee ever had a Program Exclusion taken against you? 6. Have you or any employee ever had a Program Debarment taken against you? 7. Have you or any employee ever had a Pending Criminal Judgment taken 8. Have you or any employee ever had a Pending Civil Judgment taken 9. Have you or any employee ever had a Judgment Pending Under False Claims Act taken 10. Have you or any employee ever had a Criminal Fine taken
Name 11. Have you or any employee ever had a Civil Monetary Penalty taken 12. Has applicant or employees ever been placed on the MED, LEIE, or similar database? 13. Has applicant or employees ever been charged with or convicted of any theft or fraud type crime(s)? 14. Has any State or Federal health care program ever taken any type of administrative action against applicant or employees? 15. Has Applicant, or employees, ever been charged with or convicted of any health related crimes? 16. Has Applicant, or employees, ever been charged with or convicted of a crime involving the abuse or a child or an elder/ vulnerable adult? 17. Have you paid an Enrollment Fee to Medicare in the past 5 years? 18. If you have not paid Medicare or Medicaid (out of state or in state) Enrollment Fee, have you obtained a Hardship Waiver? Please save and return saved forms to melanie.powell@hsc.utah.edu
Provider User Access Agreement Utah Department of Health, Division of Medicaid and Health Financing Section 1 - User Information Name Email address Utah-ID Employer Department/Office Job Title Street Address City/State/Zip Work phone # Supervisor Name Supervisor email Supervisor phone # Section 2 - Access Information New Change Suspend Remove (check one) Request Date Effective Date Expiration Date (If temp access) Requested Access (to see a profile description, hover over the profile checkbox) Provider Domain Name: PROVIDER Credentialing Specialist EDI Team File View (inquiry) Upload Files PROVIDER EHR Incentive Specialist (emipp system admin) PROVIDER SECURITY Account Administrator (account admin requires additional approval in Section 4 below) Justification for access (required) Section 3 - Security Agreement/Approvals User Acknowledgement- I agree to comply with the Utah Department of Health, Division of Medicaid and Health Financing PRISM Access Agreement (located at medicaid.utah.gov/become-medicaid-provider) and all other policies that are appropriate to the system profile assigned for my use. User Signature: Date: Provider Approval- I attest the requested access profile is appropriate and necessary for this individual to perform his/her assigned job duties. I understand training on system use is the supervisor s responsibility. Any changes in this employee s job duties which impact system use will be promptly reported to our PRISM account administrator. Provider Signature: Section 4 Account Administrator Agreement/Approval Date: User Acknowledgement (initial) I additionally acknowledge the Provider Account Administrator access profile is considered privileged access for the purpose of user management and includes other security duties such as, but not limited to, maintaining appropriate access documentation and performing activity reviews. Provider Approval (initial) I additionally authorize this individual to serve as the PRISM account administrator for my organization. Section 4 - Security Tracking for Provider Account Administrator Completed by Reviewed by Security Notes Date Completed Date Reviewed scanned form uploaded to PRISM rev 10/16
UTAH DEPARTMENT OF HEALTH DIVISION OF MEDICAID AND HEALTH FINANCING PROVIDER AGREEMENT FOR MEDICAID This is a Provider Agreement for participation in Title XIX of the Social Security Act (Medicaid). This agreement is between the Utah Department of Health, Division of Medicaid and Health Financing, hereafter referred to as DEPARTMENT, and (Provider Name), hereafter referred to as PROVIDER. (Billing Address for PROVIDER) (Practice Address, if different) City State Zip City State Zip PROVIDER is (mark one): Individual Partnership Corporation Other (specify) DEFINITIONS Billed charges: The usual and customary charges for the services rendered to the general public. Contractor: Includes any contractor, subcontractor, agent, or other person which or who, on behalf of the entity, furnishes, or otherwise authorizes the furnishing of Medicaid health care items or services, performs billing or coding functions, or is involved in monitoring of health care provided by the entity. Entity: Includes a governmental agency, organization, unit, corporation, partnership, or other business arrangement (including any Medicaid managed care organization, irrespective of the form of business structure or arrangement by which it exists), whether for-profit or not-for-profit, which receives or makes payments, under a State plan approved under title XIX or under any waiver of such plan, totaling at least $5,000,000 annually. Immediate access to records: When authorized DEPARTMENT employees request access to records relevant to claims submitted for services furnished under any medical assistance programs without prior notice and without delay. Immediate access shall only be requested when the DEPARTMENT employee reasonably believes the records will be destroyed or altered, and no other less intrusive method of obtaining the records is reasonably available. Unless the authorized DEPARTMENT employee has obtained a search warrant, PROVIDER shall have 24 hours to produce the records. Medical assistance: Services provided under Medicaid. Ownership interest: Direct (or indirect) ownership or control interest totaling 5% or more (see 42 CFR 455.102 to calculate ownership or control percentages). Provider: The medical professional or organization that executes this agreement as well as any of PROVIDER S employees or other persons acting for PROVIDER. Reasonable access to records: A written request from an authorized DEPARTMENT employee requesting access to records relevant to claims submitted for services furnished under any medical assistance programs delivered during normal business hours. The request must include a statement of the authority for the request, Revised: 3/1/11 Page 1 of 8
PROVIDER Type or Print PROVIDER Name Type or Print Name of Corporation PROVIDER Signature Date: DEPARTMENT PROVIDER is hereby accepted. National Provider Identifier or Medicaid Number Type or Print Title of Authorized Party Date: Signature of Authorized Party Division of Medicaid and Health Financing - Utah State Department of Health Revised: 3/1/11 Page 8 of 8
Name Final Adverse Legal Actions Please read the following information and answer the one question at the end. Topic Summary The topic requests information about final adverse actions imposed against the applicant. Examples of final adverse actions that must be reported include convictions, exclusion, revocations, and suspensions. All applicable final adverse actions must be reported, regardless of whether any records were expunged or any appeals are pending. If you are uncertain as to whether an action falls within one of the final adverse action categories or whether a name reported on this application has a final adverse action, query the Healthcare Integrity and Protection Data Bank. For information on how to access the data bank, call 1-800-767-6732 or visit www.npdb-hipdb.com. There is a charge for using this service. Final Adverse Actions that Must Be Reported Convictions 1. If you were, within the last 10 years preceding enrollment/registration, convicted of a Federal or State felony offense, you must report it in this section. Reportable offenses include, but are not limited to: a. Felony crimes against persons and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pre-trial diversions; b. Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pre-trial diversions; c. Any felony that placed the Medicare program or its beneficiaries at immediate risk (such as a malpractice suit that results in a conviction of criminal neglect or misconduct); and d. Any felonies that would result in a mandatory exclusion under Section 1128(a) of the Social Security Act. 2. Any misdemeanor conviction, under Federal or State law, related to: (a) the delivery of an item or service under Medicare or a State health care program, or (b) the abuse or neglect of a patient in connection with the delivery of a health care item or service. 3. Any misdemeanor conviction, under Federal or State law, related to theft, fraud, embezzlement, breach of fiduciary duty, or other financial misconduct in connection with the delivery of a health care item or service.
Name 4. Any felony or misdemeanor conviction, under Federal or State law, relating to the interference with or obstruction of any investigation into any criminal offense described in 42 C.F.R. Section 1001.101 or 1001.201. 5. Any felony or misdemeanor conviction, under Federal or State law, relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance. Exclusions, Revocations or Suspensions 1. Any revocation or suspension of a license to provide health care by any State licensing authority. This includes the surrender of such a license while a formal disciplinary proceeding was pending before a State licensing authority. 2. Any revocation or suspension of accreditation. 3. Any suspension or exclusion from participation in, or any sanction imposed by, a Federal or State health care program, or any debarment from participation in any Federal Executive Branch procurement or non-procurement program. 4. Any current Medicare payment suspension under any Medicare billing number. 5. Any Medicare revocation of any Medicare billing number. Has a final adverse action ever been imposed against an applicant under any current or former name or business entity? No Yes* *If yes, you will need to include supporting documents with the final outcomes with your reply so that I can upload them into your application.