Healthcare Practice Application

Healthcare Practice Application

Practice Identification

Sole Proprietorship    Partnership    Corporation    LLC    Other (explain below)

Primary Contacts

Ownership and Management

List all individuals or entities with an ownership or controlling interest equal to or greater than five percent (5%). Attach additional sheets if necessary.

Services and Capacity

Indicate services performed at this practice location.

Primary Care    Behavioral Health    Specialty Care    Urgent Care    Telehealth    Laboratory Services

Imaging/Radiology    Ambulatory Surgery    Pharmacy Services    Other

Practitioner Roster (primary clinicians at this location)

Provide professional identification for principal clinicians. Include copies of licenses and board certifications with application.

Licensure, Accreditation and Enrollment Numbers

Professional Liability Insurance

Attachments Checklist

Please indicate which documents are attached with this application. Attach copies where applicable; originals will be requested as needed.

State License Copies (facility and clinicians)
Evidence of Professional Liability Insurance
Completed Tax Form (W-9 or equivalent)
Organizational Documents (Articles of Incorporation, Operating Agreement)
Board Certifications (if applicable)
List of Corporate Officers / Managing Partners

Attestations and Certifications

By submitting this application and signing below, the applicant certifies the following under penalty of law:

1. The information provided in this application and all supporting documents is true, accurate and complete to the best of the applicant's knowledge. The applicant understands that knowingly submitting false information may be grounds for denial of participation or termination and may subject the applicant to civil or criminal penalties.

2. The applicant authorizes the organization to verify any information supplied, including verification of licensure, education, malpractice history, criminal background checks where permitted, and to contact current or previous employers, insurers, licensing boards and educational institutions.

3. The applicant affirms it maintains policies and procedures necessary to comply with applicable privacy and security laws, including protections for individually identifiable health information, and will maintain compliance with applicable state and federal requirements governing patient privacy and confidentiality.

4. The applicant agrees to notify the credentialing authority in writing within thirty (30) days of any material change to the information contained in this application, including but not limited to changes in ownership, management, licensure status, malpractice claims or insurance coverage.

5. Submission of this application does not guarantee enrollment, participation, or contracting. The credentialing authority reserves the right to request additional documentation, deny enrollment, or terminate participation in accordance with its policies.

6. The applicant will indemnify and hold harmless the credentialing authority and its agents for actions taken in good faith reliance on the information provided, except to the extent caused by the credentialing authority's gross negligence or willful misconduct.

I hereby authorize the release of any medical, billing, credentialing, malpractice and professional information necessary to evaluate this application. This authorization remains in effect until the expiration date noted above or until revoked in writing.

Acknowledgment of Policies

The applicant acknowledges receipt of and agrees to comply with the credentialing authority's policies and procedures related to provider enrollment, quality assurance, and billing. Failure to comply may result in suspension or termination of privileges.

Please certify the following by checking the boxes below:

I certify the information is true and accurate.
I authorize verification of credentials and background checks.
I agree to comply with applicable privacy, security and billing laws and policies.

Additional Information

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