Healthcare Provider Enrollment Form

HEALTHCARE PROVIDER ENROLLMENT FORM

Provider Identification

Provider Name:

Organization/Group Name (if applicable):

Contact & Practice Information

Professional Credentials

Insurance, Hospital Privileges & Liability

Payer Enrollment & Practice Capabilities

Medicare Enrolled:    Medicaid Enrolled:    Other Payer Enrolled:

Yes    No

Disclosure, Attestation and Authorization

By signing below, Provider attests that all information supplied on this Enrollment Form and any attachments is true, complete and accurate to the best of Provider's knowledge. Provider understands that material misrepresentation or omission may constitute cause for denial or termination of participation. Provider authorizes verification of credentials, licensure, professional liability insurance, hospital privileges, and other information necessary to establish eligibility. Provider agrees to promptly notify the organization of any material changes to the information provided, including changes to licensure, sanctions, adverse actions, or limitations on privileges.

Provider certifies that Provider has not been excluded, debarred, or otherwise sanctioned by any federal, state, or private payer; that there are no pending investigations that would likely result in such actions; and that Provider is in good standing with relevant licensing and certification authorities. If Provider is an organization signing on behalf of multiple practitioners, Provider certifies that it has authority to bind the practitioners listed in any attached roster.

Authorization to Release Information: Provider hereby authorizes any and all entities, including educational institutions, hospitals, governmental agencies, licensing boards, and insurers, to release information regarding Provider's qualifications, competence, licensure, disciplinary history, malpractice claims history, and other relevant data to the organization for purposes of enrollment, credentialing, and downstream payer verification. This authorization remains effective until revoked in writing.

Attachments & Required Documentation

Attach copies of the following where applicable: current state license(s), board certification, DEA certificate, current professional liability declarations page, curriculum vitae, government-issued photo ID, and hospital privilege letters. Provider understands that credentialing is contingent upon receipt and verification of required documentation.

Acknowledgment of Privacy

Provider acknowledges receipt of and agrees to comply with the organization's privacy and security policies applicable to protected health information. Provider agrees to maintain appropriate safeguards and to execute any business associate agreement required for exchange of protected health information.

Sign Now