Healthcare Professional Corporation

HEALTHCARE PROFESSIONAL CORPORATION ORGANIZATION & CREDENTIALING FORM

This form collects organizational, professional and credentialing information for a Healthcare Professional Corporation seeking recognition, enrollment, credentialing, or affiliation. Completion and signature by an authorized corporate officer constitutes certification under penalty of perjury that the information provided is true, complete and accurate to the best of the signer's knowledge, and that the corporation will comply with applicable laws and professional practice requirements.

1. CORPORATION IDENTIFICATION

Entity Type: Professional Corporation Limited Liability Company (for professional services) Other

State of Formation:    Date of Incorporation:

Business Phone:    Business Email:

2. CORPORATE NPI & PAYOR IDENTIFIERS

3. PROFESSIONAL SHAREHOLDERS / LICENSED PROVIDERS

Provide information for each licensed professional who is a shareholder, director, officer or who will render professional services on behalf of the corporation. Attach additional pages if necessary.

License Type/Discipline:    License Number:    Issuing State:

NPI Number:    Date of Birth:

Specialty:    Contact Phone:

License Type/Discipline:    License Number:    Issuing State:

NPI Number:    Date of Birth:

Specialty:    Contact Phone:

4. OFFICERS & REGISTERED AGENT

5. PROFESSIONAL LIABILITY INSURANCE

Policy Number:    Limits of Liability:

Effective Date:    Expiration Date:

6. SCOPE OF PROFESSIONAL SERVICES

7. ATTESTATIONS, REPRESENTATIONS AND CERTIFICATIONS

By signing below, the authorized officer certifies and represents that: (a) the corporation was duly formed under the laws of the State of formation identified above and is properly authorized to conduct the professional services described herein; (b) all shareholders, officers and persons providing professional services on behalf of the corporation hold currently valid and unrestricted licenses in the jurisdiction(s) where services are rendered; (c) the corporation and its professionals are not currently excluded from participation in federal health care programs and will notify the requesting organization in writing within thirty (30) days of any change in legal or licensure status, malpractice claims made against the corporation or its providers, disciplinary actions, or exclusions; (d) the information provided in this form is true, complete and accurate to the best of the signer's knowledge, and the signer understands that intentional falsification or omission of material facts may subject the signer and the corporation to civil and/or criminal penalties and may result in denial or termination of membership, privileges, contracts, or payor enrollment.

The corporation further certifies that it maintains policies and procedures to ensure that professional services are rendered only by appropriately licensed individuals and that records of services rendered will be maintained in compliance with applicable law and retained for the minimum period required by law.

8. HIPAA AUTHORIZATION & PRIVACY ACKNOWLEDGMENT

The corporation acknowledges its obligations under applicable health information privacy laws and certifies that it has implemented administrative, physical and technical safeguards to protect protected health information. The corporation authorizes the release of professional, licensure, disciplinary, malpractice and credentialing records, and limited protected health information, as necessary for credentialing, contracting, payor enrollment, utilization review and quality assessment, in accordance with applicable law.

HIPAA & Privacy Acknowledgment: I acknowledge and certify that the corporation will comply with HIPAA privacy and security requirements and will provide required privacy notices as applicable.

9. DISCLOSURES

Has any shareholder, officer or provider associated with the corporation ever had a professional license suspended, revoked, restricted, or subject to disciplinary action, or been sanctioned by a government agency, or been convicted of a felony related to health care?    Yes No

10. AUTHORIZED REPRESENTATIVE CERTIFICATION

I certify under penalty of perjury under the laws of the applicable jurisdiction that I am an authorized officer or agent of the corporation and that the foregoing information is accurate and complete. I authorize release of information necessary to verify the statements made in this form, including verification of licensure, board certification, malpractice history, and government program exclusions.

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