Healthcare Integrity Application

HEALTHCARE INTEGRITY APPLICATION

Purpose: Use this application to provide identifying, licensure, credentialing, and integrity-related information for evaluation of participation in healthcare programs, networks, or agreements. Complete all sections fully and attach required documentation where indicated. Incomplete responses may delay review.

Applicant / Entity Information

Applicant Name:

Individual Practitioner    Group / Practice    Facility    Vendor / Contractor    Other:

Contact & Demographic Information

Insurance / Billing Identifiers

Employment, Ownership & Affiliations

Do you or any related party hold a 5% or greater ownership interest in any healthcare entity?   Yes    No

Integrity & Background Disclosures

1. Exclusions / Debarments: Have you or the organization ever been excluded, debarred, suspended, or otherwise ineligible to participate in any federal or state healthcare program?   Yes    No

2. Criminal Convictions: Have you or an owner/officer been convicted of, pled guilty or nolo contendere to, or had a judgment entered for any felony, or any crime related to health care, controlled substances, or fraud?   Yes    No

3. Civil Judgments, Exclusions from Managed Care, or Monetary Settlements related to healthcare?   Yes    No

4. Professional Liability / Malpractice Claims: Have there been any paid malpractice claims, settlements, or judgments against you or your organization in the past 10 years?   Yes    No

5. Bankruptcy or Insolvency Proceedings in the past 7 years?   Yes    No

References

Consent, Authorization & Acknowledgments

By signing below, the applicant certifies under penalty of perjury that all information contained in this application and any attachments is true, complete, and correct to the best of the applicant's knowledge. Applicant authorizes the organization, its agents, and authorized state and federal oversight bodies to verify information provided, to obtain and review credentialing, disciplinary, licensing, criminal, exclusion, and claims history, and to contact references and prior employers. Applicant further releases from liability any person or entity that furnishes such information.

Applicant consents to background checks, including but not limited to criminal background checks, national and state exclusion list checks, and verification of licensure and sanctions. Applicant further acknowledges the obligation to promptly notify the organization in writing of any changes to information provided herein, and of any event that may affect eligibility to participate in federal or state healthcare programs.

HIPAA Acknowledgment: Applicant acknowledges obligation to maintain the privacy and security of protected health information and affirms that appropriate policies, training, and safeguards are in place for any services that will access PHI.   I acknowledge and agree

Certifications & Legal Notices

Certification of Accuracy: Applicant understands that intentional omission, falsification, or misrepresentation of information is grounds for denial of this application, termination of any participation agreement, and may constitute a crime under applicable law subject to criminal and civil penalties, including fines and imprisonment.

Duty to Report: Applicant agrees to report immediately in writing any criminal convictions, disciplinary actions, exclusions, or changes in licensure status that occur after submission of this application and prior to any executed participation agreement.

Record Retention & Release: Applicant authorizes release of application materials and verification records to auditors, payors, and governmental agencies as required by law or contract. Applicant agrees to keep and make available documented evidence of credentials, training, and insurance upon request.

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