Texas Standardized Credentialing Application (Please type or print)

Education - continued

POST-GRADUATE EDUCATION

Program successfully completed

ATTENDANCE DATES (MM/YYYY TO MM/YYYY)

PROGRAM DIRECTOR

CURRENT PROGRAM DIRECTOR (IF KNOWN)

Please check this box and complete and submit Attachment B if you received additional postgraduate training.

OTHER GRADUATE-LEVEL EDUCATION

Issuing Institution:

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

DEGREE

ATTENDANCE DATES (MM/YYYY TO MM/YYYY)

Licenses and Certificates - Please include all license(s) and certifications in all States where you are currently or

have previously been licensed.

LICENSE TYPE

LICENSE NUMBER

STATE OF REGISTRATION

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

DO YOU CURRENTLY PRACTICE IN THIS STATE? Yes No

LICENSE TYPE

LICENSE NUMBER

STATE OF REGISTRATION

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

DO YOU CURRENTLY PRACTICE IN THIS STATE? Yes No

LICENSE TYPE

LICENSE NUMBER

STATE OF REGISTRATION

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

DO YOU CURRENTLY PRACTICE IN THIS STATE? Yes No

DEA Number:

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

DPS Number:

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

OTHER CDS (PLEASE SPECIFY)

NUMBER

STATE OF REGISTRATION

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

DO YOU CURRENTLY PRACTICE IN THIS STATE? Yes No

UPIN

NATIONAL PROVIDER IDENTIFIER (WHEN AVAILABLE)

ARE YOU A PARTICIPATING MEDICARE PROVIDER? Yes No Medicare Provider Number:

ARE YOU A PARTICIPATING MEDICAID PROVIDER? Yes No Medicaid Provider Number:

EDUCATIONAL COUNCIL FOR FOREIGN MEDICAL GRADUATES (ECFMG) N/A Yes No ECFMG Number:

ECFMG ISSUE DATE (MM/DD/YYYY)

Professional/Specialty Information

PRIMARY SPECIALTY

BOARD CERTIFIED?

Yes No Name of Certifying Board:

INITIAL CERTIFICATION DATE (MM/YYYY)

RECERTIFICATION DATE(S), IF APPLICABLE (MM/YYYY)

EXPIRATION DATE, IF APPLICABLE (MM/YYYY)

IF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT APPLY. I have taken exam, results pending for Board.

I have taken Part I and am eligible for Part II of the Exam. I am intending to sit for the Boards on (date)

I am not planning to take Boards.

DO YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY? HMO: Yes No PPO: Yes No POS: Yes No

SECONDARY SPECIALTY

BOARD CERTIFIED?

Yes No Name of Certifying Board:

INITIAL CERTIFICATION DATE (MM/YYYY)

RECERTIFICATION DATE(S), IF APPLICABLE (MM/YYYY)

EXPIRATION DATE, IF APPLICABLE (MM/YYYY)

Professional/Specialty Information -continued

IF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT APPLY. I have taken exam, results pending for Board.

I have taken Part I and am eligible for Part II of the Exam. I am intending to sit for the Boards on (date)

I am not planning to take Boards.

DO YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY? HMO: Yes No PPO: Yes No POS: Yes No

ADDITIONAL SPECIALTY

BOARD CERTIFIED?

Yes No Name of Certifying Board:

INITIAL CERTIFICATION DATE (MM/YYYY)

RECERTIFICATION DATE(S), IF APPLICABLE (MM/YYYY)

EXPIRATION DATE, IF APPLICABLE (MM/YYYY)

IF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT APPLY. I have taken exam, results pending for Board.

I have taken Part I and am eligible for Part II of the Exam. I am intending to sit for the Boards on (date)

I am not planning to take Boards.

DO YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY? HMO: Yes No PPO: Yes No POS: Yes No

PLEASE LIST OTHER AREAS OF PROFESSIONAL PRACTICE INTEREST OR FOCUS (HIV/AIDS, ETC.)

Work History - Please provide a chronological work history. You may submit a Curriculum Vitae as

a supplement. Please explain all gaps in employment that lasted more than six months.

CURRENT PRACTICE/EMPLOYER NAME

START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PREVIOUS PRACTICE/EMPLOYER NAME

START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

REASON FOR DISCONTINUANCE

PREVIOUS PRACTICE/EMPLOYER NAME

START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

REASON FOR DISCONTINUANCE

PREVIOUS PRACTICE/EMPLOYER NAME

START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

REASON FOR DISCONTINUANCE

PLEASE PROVIDE AN EXPLANATION FOR ANY GAPS GREATER THAN SIX MONTHS (MM/YYYY TO MM/YYYY) IN WORK HISTORY. Gap Dates: Explanation:

Gap Dates: Explanation:

Work History – continued

Gap Dates: Explanation:

Gap Dates: Explanation:

Please check this box and complete and submit Attachment C if you have additional work history

Hospital Affiliations-Please include all hospitals where you currently have or have previously had privileges.

DO YOU HAVE HOSPITAL PRIVILEGES? Yes No

IF YOU DO NOT HAVE ADMITTING PRIVILEGES, WHAT ADMITTING ARRANGEMENTS DO YOU HAVE?

PRIMARY HOSPITAL WHERE YOU HAVE ADMITTING PRIVILEGES

START DATE (MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX

E-MAIL

FULL UNRESTRICTED PRIVILEGES? Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

ARE PRIVILEGES TEMPORARY? Yes No

OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO PRIMARY HOSPITAL?

OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES

START DATE (MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX

E-MAIL

FULL UNRESTRICTED PRIVILEGES? Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

ARE PRIVILEGES TEMPORARY? Yes No

OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?

Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

FULL UNRESTRICTED PRIVILEGES? Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

WERE PRIVILEGES TEMPORARY? Yes No

REASON FOR DISCONTINUANCE

Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.

References-Please provide three peer references from the same field and/or specialty who are not partners in your own group practice and are not relatives. All peer references should have firsthand knowledge of your abilities.

1 NAME/TITLE

PHONE NUMBER

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

References- continued

2 NAME/TITLE

PHONE NUMBER

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

3 NAME/TITLE

PHONE NUMBER

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

Professional Liability Insurance Coverage

SELF-INSURED? Yes No

NAME OF CURRENT MALPRACTICE INSURANCE CARRIER OR SELF-INSURED ENTITY

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

POLICY NUMBER

EFFECTIVE DATE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

AMOUNT OF COVERAGE PER OCCURRENCE

AMOUNT OF COVERAGE AGGREGATE

TYPE OF COVERAGE

Individual Shared

LENGTH OF TIME WITH CARRIER

NAME OF PREVIOUS MALPRACTICE INSURANCE CARRIER IF WITH CURRENT CARRIER LESS THAN 5 YEARS

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

POLICY NUMBER

EFFECTIVE DATE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

AMOUNT OF COVERAGE PER OCCURRENCE

AMOUNT OF COVERAGE AGGREGATE

TYPE OF COVERAGE

Individual Shared

LENGTH OF TIME WITH CARRIER

Call Coverage

See attached list of hospital staff within my department I utilize for call coverage.

PLEASE LIST NAMES OF COLLEAGUE(S) PROVIDING REGULAR COVERAGE AND HIS OR HER SPECIALTIES. Name: Specialty:

Name: Specialty:

Name: Specialty:

Name: Specialty:

Name: Specialty:

PLEASE LIST FULL NAMES OF ALL PARTNERS IN YOUR PRACTICE. CHECK THIS BOX AND ATTACH LIST FOR LARGE GROUP. Name: Name:

Name: Name:

Name: Name:

Name: Name:

Practice Location Information - Please answer the following questions for each practice location. Use Attachment F or make copies of pages 6-7 as necessary.

PRACTICE LOCATION

of

TYPE OF SERVICE PROVIDED

Solo Primary Care Solo Specialty Care Group Primary Care Group Single Specialty Group Multi-Specialty

GROUP NAME/PRACTICE NAME TO APPEAR IN THE DIRECTORY

GROUP/CORPORATE NAME AS IT APPEARS ON IRS W-9

PRACTICE LOCATION ADDRESS Primary

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX NUMBER

E-MAIL

BACK OFFICE PHONE NUMBER

SITE-SPECIFIC MEDICAID NUMBER

TAX ID NUMBER

GROUP NUMBER CORRESPONDING TO TAX ID NUMBER

GROUP NAME CORRESPONDING TO TAX ID NUMBER

ARE YOU CURRENTLY PRACTICING AT THIS LOCATION? Yes No

IF NO, EXPECTED START DATE? (MM/DD/YYYY)

DO YOU WANT THIS LOCATION LISTED IN THE DIRECTORY? Yes No

OFFICE MANAGER OR STAFF CONTACT

PHONE NUMBER

FAX NUMBER

CREDENTIALING CONTACT

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX NUMBER

E-MAIL

BILLING COMPANY'S NAME (IF APPLICABLE)

BILLING REPRESENTATIVE

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX NUMBER

E-MAIL

DEPARTMENT NAME IF HOSPITAL-BASED

CHECK PAYABLE TO

CAN YOU BILL ELECTRONICALLY? Yes No

HOURS PATIENTS ARE SEEN

Monday No Office Hours Morning: Afternoon: Evening: Tuesday No Office Hours Morning: Afternoon: Evening: Wednesday No Office Hours Morning: Afternoon: Evening: Thursday No Office Hours Morning: Afternoon: Evening: Friday No Office Hours Morning: Afternoon: Evening: Saturday No Office Hours Morning: Afternoon: Evening:

Sunday No Office Hours Morning: Afternoon: Evening:

DOES THIS LOCATION PROVIDE 24 HOUR/7 DAY A WEEK PHONE COVERAGE?

Answering Service Voice mail with instructions to call answering service Voice mail with other instructions None

THIS PRACTICE LOCATION ACCEPTS

all new patients existing patients with change of payor new patients with referral new Medicare patients new Medicaid patients

IF NEW PATIENT ACCEPTANCE VARIES BY HEALTH PLAN, PLEASE PROVIDE EXPLANATION.

PRACTICE LIMITATIONS

Male only Female only Age: Other:

DO NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS, MIDWIVES, SOCIAL WORKERS OR OTHER NON-PHYSICIAN PROVIDERS CARE FOR PATIENTS AT THIS PRACTICE LOCATION?

Yes No If yes, provide the following information for each staff member:

NAME PROFESSIONAL DESIGNATION STATE & LICENSE NO.

NAME PROFESSIONAL DESIGNATION STATE & LICENSE NO.

Practice Location Information - continued

NAME PROFESSIONAL DESIGNATION STATE & LICENSE NO.

NAME PROFESSIONAL DESIGNATION STATE & LICENSE NO.

NAME PROFESSIONAL DESIGNATION STATE & LICENSE NO.

NAME PROFESSIONAL DESIGNATION STATE & LICENSE NO.

NON-ENGLISH LANGUAGES SPOKEN BY HEALTH CARE PROVIDERS

NON-ENGLISH LANGUAGES SPOKEN BY OFFICE PERSONNEL

ARE INTERPRETERS AVAILABLE?

Yes No If yes, please specify languages:

DOES THIS PRACTICE LOCATION MEET ADA ACCESSIBILITY STANDARDS? Yes No

WHICH OF THE FOLLOWING FACILITIES ARE HANDICAPPED ACCESSIBLE? Building Parking Restroom Other:

DOES THIS LOCATION HAVE OTHER SERVICES FOR THE DISABLED?

Text Telephony-TTY American Sign Language-ASL Mental/Physical Impairment Services 0ther:

IS THIS LOCATION ACCESSIBLE BY PUBLIC TRANSPORTATION? Bus Regional Train Other:

DOES THIS LOCATION PROVIDE CHILDCARE SERVICES? Yes No

DOES THIS LOCATION QUALIFY AS A MINORITY BUSINESS ENTERPRISE? Yes No

WHO AT THIS LOCATION HAVE THE FOLLOWING CURRENT CERTIFICATIONS? (PLEASE LIST ONLY THE APPLICANT'S CERTIFICATION EXPIRATION DATES.)

Basic Life Support Staff Provider Exp: Advanced Life Support in OB Staff Provider Exp: Advanced Trauma Life Support Staff Provider Exp: Cardio-Pulmonary Resuscitation Staff Provider Exp: Advanced Cardiac Life Support Staff Provider Exp: Pediatric Advanced Life Support Staff Provider Exp: Neonatal Advanced Life Support Staff Provider Exp: Other (please specify) Staff Provider Exp:

DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? Yes No

Laboratory Services; please list all Certificates of Participation (CLIA, AAFP, COLA, CAP, MLE):

DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? Yes No

X-ray; please list all certifications:

OTHER SERVICES

Radiology Services EKG Care of Minor Lacerations Pulmonary Function Tests

Allergy Injections Allergy Skin Tests Routine Office Gynecology Drawing Blood

Age Appropriate Immunizations Flexible Sigmoidoscopy Tympanometry/Audiometry Tests Asthma Treatments Osteopathic Manipulations IV Hydration /Treatments Cardiac Stress Tests Physical Therapies Other:

PLEASE LIST ANY ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)

IS ANESTHESIA ADMINISTERED AT THIS PRACTICE LOCATION? Yes No Please specify the classes or categories:

WHO ADMINISTERS IT?

Please check this box and complete and submit Attachment F if you have other practice locations.

QUESTION NUMBER

PLE ASE EXPLAIN

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

DEGREE

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

DEGREE

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

DEGREE

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

DEGREE

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

DEGREE

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

DEGREE

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

DEGREE

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

OTHER POST-GRADUATE EDUCATION SPECIALTY Internship Residency Fellowship Teaching Appointment

INSTITUTION

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

Program successfully completed

ATTENDANCE DATES (MM/YYYY TO MM/YYYY)

PROGRAM DIRECTOR

CURRENT PROGRAM DIRECTOR (IF KNOWN)

OTHER POST-GRADUATE EDUCATION SPECIALTY Internship Residency Fellowship Teaching Appointment

INSTITUTION

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

Program successfully completed

ATTENDANCE DATES (MM/YYYY TO MM/YYYY)

PROGRAM DIRECTOR

CURRENT PROGRAM DIRECTOR (IF KNOWN)

OTHER POST-GRADUATE EDUCATION SPECIALTY Internship Residency Fellowship Teaching Appointment

INSTITUTION

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

Program successfully completed

ATTENDANCE DATES (MM/YYYY TO MM/YYYY)

PROGRAM DIRECTOR

CURRENT PROGRAM DIRECTOR (IF KNOWN)

OTHER POST-GRADUATE EDUCATION SPECIALTY Internship Residency Fellowship Teaching Appointment

INSTITUTION

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

Program successfully completed

ATTENDANCE DATES (MM/YYYY TO MM/YYYY)

PROGRAM DIRECTOR

CURRENT PROGRAM DIRECTOR (IF KNOWN)

OTHER POST-GRADUATE EDUCATION SPECIALTY Internship Residency Fellowship Teaching Appointment

INSTITUTION

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

Program successfully completed

ATTENDANCE DATES (MM/YYYY TO MM/YYYY)

PROGRAM DIRECTOR

CURRENT PROGRAM DIRECTOR (IF KNOWN)

PREVIOUS PRACTICE/EMPLOYER NAME

START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

REASON FOR DISCONTINUANCE

PREVIOUS PRACTICE/EMPLOYER NAME

START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

REASON FOR DISCONTINUANCE

PREVIOUS PRACTICE/EMPLOYER NAME

START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

REASON FOR DISCONTINUANCE

PREVIOUS PRACTICE/EMPLOYER NAME

START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

REASON FOR DISCONTINUANCE

PREVIOUS PRACTICE/EMPLOYER NAME

START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

REASON FOR DISCONTINUANCE

PREVIOUS PRACTICE/EMPLOYER NAME

START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

REASON FOR DISCONTINUANCE

PREVIOUS PRACTICE/EMPLOYER NAME

START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

REASON FOR DISCONTINUANCE

OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES

START DATE (MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX

E-MAIL

FULL UNRESTRICTED PRIVILEGES?

Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

ARE PRIVILEGES TEMPORARY?

Yes No

OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?

OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES

START DATE (MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX

E-MAIL

FULL UNRESTRICTED PRIVILEGES?

Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

ARE PRIVILEGES TEMPORARY?

Yes No

OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?

OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES

START DATE (MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX

E-MAIL

FULL UNRESTRICTED PRIVILEGES?

Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

ARE PRIVILEGES TEMPORARY?

Yes No

OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?

OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES

START DATE (MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX

E-MAIL

FULL UNRESTRICTED PRIVILEGES?

Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

ARE PRIVILEGES TEMPORARY?

Yes No

OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?

OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES

START DATE (MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX

E-MAIL

FULL UNRESTRICTED PRIVILEGES?

Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

ARE PRIVILEGES TEMPORARY?

Yes No

OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

FULL UNRESTRICTED PRIVILEGES?

Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

WERE PRIVILEGES TEMPORARY?

Yes No

REASON FOR DISCONTINUANCE

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

FULL UNRESTRICTED PRIVILEGES?

Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

WERE PRIVILEGES TEMPORARY?

Yes No

REASON FOR DISCONTINUANCE

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

FULL UNRESTRICTED PRIVILEGES?

Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

WERE PRIVILEGES TEMPORARY?

Yes No

REASON FOR DISCONTINUANCE

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

FULL UNRESTRICTED PRIVILEGES?

Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

WERE PRIVILEGES TEMPORARY?

Yes No

REASON FOR DISCONTINUANCE

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

FULL UNRESTRICTED PRIVILEGES?

Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

WERE PRIVILEGES TEMPORARY?

Yes No

REASON FOR DISCONTINUANCE

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

FULL UNRESTRICTED PRIVILEGES?

Yes No

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

WERE PRIVILEGES TEMPORARY?

Yes No

REASON FOR DISCONTINUANCE

Practice Location Information - Please answer the following questions for each practice location. Use Attachment F or make copies of pages 6-7 as necessary.

PRACTICE LOCATION

of

TYPE OF SERVICE PROVIDED

Solo Primary Care Solo Specialty Care Group Primary Care Group Single Specialty Group Multi-Specialty

GROUP NAME/PRACTICE NAME TO APPEAR IN THE DIRECTORY

GROUP/CORPORATE NAME AS IT APPEARS ON IRS W-9

PRACTICE LOCATION ADDRESS Primary

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX NUMBER

E-MAIL

BACK OFFICE PHONE NUMBER

SITE-SPECIFIC MEDICAID NUMBER

TAX ID NUMBER

GROUP NUMBER CORRESPONDING TO TAX ID NUMBER

GROUP NAME CORRESPONDING TO TAX ID NUMBER

ARE YOU CURRENTLY PRACTICING AT THIS LOCATION? Yes No

IF NO, EXPECTED START DATE? (MM/DD/YYYY)

DO YOU WANT THIS LOCATION LISTED IN THE DIRECTORY? Yes No

OFFICE MANAGER OR STAFF CONTACT

PHONE NUMBER

FAX NUMBER

CREDENTIALING CONTACT

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX NUMBER

E-MAIL

BILLING COMPANY'S NAME (IF APPLICABLE)

BILLING REPRESENTATIVE

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

FAX NUMBER

E-MAIL

DEPARTMENT NAME IF HOSPITAL-BASED

CHECK PAYABLE TO

CAN YOU BILL ELECTRONICALLY? Yes No

HOURS PATIENTS ARE SEEN

Monday No Office Hours Morning: Afternoon: Evening: Tuesday No Office Hours Morning: Afternoon: Evening: Wednesday No Office Hours Morning: Afternoon: Evening: Thursday No Office Hours Morning: Afternoon: Evening: Friday No Office Hours Morning: Afternoon: Evening: Saturday No Office Hours Morning: Afternoon: Evening: Sunday No Office Hours Morning: Afternoon: Evening:

DOES THIS LOCATION PROVIDE 24 HOUR/7 DAY A WEEK PHONE COVERAGE?

Answering Service Voice mail with instructions to call answering service Voice mail with other instructions None

THIS PRACTICE LOCATION ACCEPTS

all new patients existing patients with change of payor new patients with referral new Medicare patients new Medicaid patients

IF NEW PATIENT ACCEPTANCE VARIES BY HEALTH PLAN, PLEASE PROVIDE EXPLANATION.

PRACTICE LIMITATIONS

Male only Female only Age: Other:

DO NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS, MIDWIVES, SOCIAL WORKERS OR OTHER NON-PHYSICIAN PROVIDERS CARE FOR PATIENTS AT THIS PRACTICE LOCATION?

Yes No If yes, provide the following information for each staff member:

NAME PROFESSIONAL DESIGNATION STATE & LICENSE NUMBER

NAME PROFESSIONAL DESIGNATION STATE & LICENSE NUMBER

Practice Location Information - continued

NAME PROFESSIONAL DESIGNATION STATE & LICENSE NUMBER

NAME PROFESSIONAL DESIGNATION STATE & LICENSE NUMBER

NAME PROFESSIONAL DESIGNATION STATE & LICENSE NUMBER

NAME PROFESSIONAL DESIGNATION STATE & LICENSE NUMBER

NON-ENGLISH LANGUAGES SPOKEN BY HEALTH CARE PROVIDERS

NON-ENGLISH LANGUAGES SPOKEN BY OFFICE PERSONNEL

ARE INTERPRETERS AVAILABLE?

Yes No If yes, please specify languages:

DOES THIS PRACTICE LOCATION MEET ADA ACCESSIBILITY STANDARDS? Yes No

WHICH OF THE FOLLOWING FACILITIES ARE HANDICAPPED ACCESSIBLE? Building Parking Restroom Other:

DOES THIS LOCATION HAVE OTHER SERVICES FOR THE DISABLED?

Text Telephony-TTY American Sign Language-ASL Mental/Physical Impairment Services 0ther:

IS THIS LOCATION ACCESSIBLE BY PUBLIC TRANSPORTATION? Bus Regional Train Other:

DOES THIS LOCATION PROVIDE CHILDCARE SERVICES? Yes No

DOES THIS LOCATION QUALIFY AS A MINORITY BUSINESS ENTERPRISE? Yes No

WHO AT THIS LOCATION HAVE THE FOLLOWING CURRENT CERTIFICATIONS? (PLEASE LIST ONLY THE APPLICANT'S CERTIFICATION EXPIRATION DATES.)

Basic Life Support Staff Provider Exp: Advanced Life Support in OB Staff Provider Exp: Advanced Trauma Life Support Staff Provider Exp: Cardio-Pulmonary Resuscitation Staff Provider Exp: Advanced Cardiac Life Support Staff Provider Exp: Pediatric Advanced Life Support Staff Provider Exp: Neonatal Advanced Life Support Staff Provider Exp: Other (please specify) Staff Provider Exp:

DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? Yes No

Laboratory Services; please list all Certificates of Participation (CLIA, AAFP, COLA, CAP, MLE):

DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? Yes No

X-ray; please list all certifications:

OTHER SERVICES

Radiology Services EKG Care of Minor Lacerations Pulmonary Function Tests

Allergy Injections Allergy Skin Tests Routine Office Gynecology Drawing Blood

Age Appropriate Immunizations Flexible Sigmoidoscopy Tympanometry/Audiometry Tests Asthma Treatments Osteopathic Manipulations IV Hydration /Treatments Cardiac Stress Tests Physical Therapies Other:

PLEASE LIST ANY ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)

IS ANESTHESIA ADMINISTERED AT THIS PRACTICE LOCATION? Yes No Please specify the classes or categories:

WHO ADMINISTERS IT?

Please check this box and complete and submit Attachment F if you have other practice locations.

INCIDENT DATE (MM/DD/YYYY)

DATE CLAIM WAS FILED (MM/DD/YYYY)

CLAIM/CASE STATUS

PROFESSIONAL LIABILITY CARRIER INVOLVED

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

POLICY NUMBER

AMOUNT OF AWARD OR SETTLEMENT & AMOUNT PAID

$ $

METHOD OF RESOLUTION

Dismissed Settled (with prejudice) Settled (without prejudice) Judgment for Defendant(s) Judgment for Plaintiff(s) Mediation or Arbitration

DESCRIPTION OF ALLEGATIONS

WERE YOU PRIMARY DEFENDANT OR CO-DEFENDANT?

NUMBER OF OTHER CO-DEFENDANTS

YOUR INVOLVEMENT (ATTENDING, CONSULTING, ETC.)

DESCRIPTION OF ALLEGED INJURY TO THE PATIENT

TO THE BEST OF YOUR KNOWLEDGE, IS THIS CASE INCLUDED IN THE NATIONAL PRACTITIONER DATA BANK (NPDB)? Yes No

INCIDENT DATE (MM/DD/YYYY)

DATE CLAIM WAS FILED (MM/DD/YYYY)

CLAIM/CASE STATUS

PROFESSIONAL LIABILITY CARRIER INVOLVED

ADDRESS

CITY STATE/COUNTRY POSTAL CODE

PHONE NUMBER

POLICY NUMBER

AMOUNT OF AWARD OR SETTLEMENT & AMOUNT PAID

$ $

METHOD OF RESOLUTION

Dismissed Settled (with prejudice) Settled (without prejudice) Judgment for Defendant(s) Judgment for Plaintiff(s) Mediation or Arbitration

DESCRIPTION OF ALLEGATIONS

WERE YOU PRIMARY DEFENDANT OR CO-DEFENDANT?

NUMBER OF OTHER CO-DEFENDANTS

YOUR INVOLVEMENT (ATTENDING, CONSULTING, ETC.)

DESCRIPTION OF ALLEGED INJURY TO THE PATIENT

TO THE BEST OF YOUR KNOWLEDGE, IS THIS CASE INCLUDED IN THE NATIONAL PRACTITIONER DATA BANK (NPDB)? Yes No