Healthcare Ancillary Application

HEALTHCARE ANCILLARY APPLICATION

Purpose: Use this application to request ancillary service enrollment and credentialing with the contracting organization. Completion of this application and submission of requested attachments authorizes verification of licenses, credentials, claims history, and insurance coverage as necessary to evaluate the applicant for participation. Incomplete or unsigned applications will not be processed.

A. APPLICANT IDENTIFICATION

B. ENTITY & TAX INFORMATION

Entity Type: Corporation LLC Sole Proprietor Partnership Other

C. SERVICES PROVIDED

Indicate ancillary services provided (check all that apply):

D. LICENSES, CREDENTIALS & INSURANCE

Provide primary professional or facility license information for the organization and clinical staff. Licenses will be verified.

Professional Liability Insurance:

E. COMPLIANCE ATTESTATIONS

Please check each box to attest. Certification: The undersigned certifies under penalty of law that the statements in this application are true and complete to the best of their knowledge. False statements may lead to denial or termination of participation.

Applicant maintains current and valid licenses, registrations and certifications required to perform the described ancillary services. Applicant maintains professional liability and other insurance coverage as reported above and will provide certificate upon request. No owner, officer, managing employee, or practitioner of the applicant is currently excluded, debarred, or otherwise ineligible to participate in federal health care programs. Applicant agrees to comply with applicable privacy and security laws and will execute a business associate agreement if required. Applicant affirms that all billing practices comply with applicable laws and contractual requirements; applicant will cooperate with audits and inquiries.

F. CLAIMS, LITIGATION & SANCTIONS

Has the applicant or any practitioner employed or contracted by the applicant had any malpractice claims, disciplinary actions, license suspensions/revocations, or criminal convictions in the last ten years?

Yes No

G. REFERENCES & SUPPORTING DOCUMENTS

Provide two professional or institutional references who can verify the applicant's qualifications and service performance.

Supporting documents checklist (attach copies): Certificate of Insurance, W-9 (or tax documentation), Copies of professional/facility licenses and certifications, Organizational chart and list of practitioners, Business Associate Agreement (if requested).

H. AUTHORIZATION & CERTIFICATION

Applicant Representative attests and certifies as follows: The information contained in this application and any attachments is true, complete and correct. Applicant authorizes verification of information provided, including but not limited to licensure, education, employment history, malpractice claims history, and insurance coverage. Applicant releases from liability any person or entity supplying such information. This authorization shall remain effective until the date specified below or until revoked in writing.

Authorization Expiration Date:

Warning: Knowingly submitting false information may result in denial, suspension, or termination of participation and may subject the signer to civil or criminal penalties under applicable law.

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