Healthcare Regulatory Profile

HEALTHCARE REGULATORY PROFILE

I. Entity Information

Entity Type: Hospital Clinic Physician Practice Long-Term Care Behavioral Health Home Health Diagnostic Lab Other

II. Authorized Representative

III. Licensure, Certification & Identifiers

State License(s) and Number(s):

DEA Registration Number (if applicable):

Medicare Provider Number(s):

Accreditation Status: Joint Commission NCQA DNV State Department Accreditation None Other

IV. Insurance, Malpractice & Financial Responsibility

V. Regulatory Compliance & Program Oversight

Incident Reporting Policy in place: Yes No If yes, identify escalation and retention requirements:

VI. Inspections, Investigations & Adverse Actions

Has the entity or any owner/controlled person been subject to any licensure suspension, revocation, civil monetary penalty, exclusion, or other adverse action within the past five years? Yes No

Disclosure of Exclusions (OIG/GSA or equivalent): Yes No

VII. Data Privacy, HIPAA Acknowledgment & Record Release

The Authorized Representative certifies that the entity maintains administrative, technical, and physical safeguards designed to protect the privacy and security of protected health information as required by applicable law. The Authorized Representative authorizes release of licensure, accreditation, inspection, and sanction records to authorized payors and regulatory reviewers upon request for the purpose of credentialing, enrollment or regulatory compliance reviews. The Authorized Representative further acknowledges the entity's obligation to notify relevant payors and regulators promptly of any changes to the information provided herein or of any adverse actions.

VIII. Insurance of Change & Notification Obligations

The Authorized Representative certifies that all information provided in this Regulatory Profile is true, complete, and accurate to the best of their knowledge. The Authorized Representative agrees to notify the requesting organization in writing within 30 days of any material change to licensure, accreditation status, insurance coverage, ownership, or adverse regulatory actions. False statements, omissions, or failure to report material changes may constitute grounds for denial, suspension, or termination of contracts and may subject the entity and signatory to penalties under applicable law.

IX. Attestations & Certifications

By signing below, the Authorized Representative certifies under penalty of perjury and other applicable sanctions that the facts set forth in this Healthcare Regulatory Profile are true, accurate and complete. The Authorized Representative authorizes verification of the information provided, including verification with licensing and accreditation bodies, insurance carriers, and governmental agencies. The Authorized Representative acknowledges that this Profile may be relied upon by payors, credentialing entities, and regulators in evaluating the entity's compliance and eligibility for participation. This certification is effective as of the Profile Effective Date and remains in force until the Profile Expiration / Review Date unless earlier amended in writing.

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