Ohio Department of Insurance Standardized Credentialing Form

Ohio Department of Insurance
Standardized Credentialing Form
Part B: Agency/Program/Organization Providers

INS5036 (Rev. 01/2011) — Accredited by the National Association of Insurance Commissioners (NAIC)

Please complete each section leaving no blank spaces. Clearly state if information requested is not applicable or not available and why.

Provider Identification

Legal Name of Applicant:

Federal Tax Identification Number:

Doing Business As (DBA):

Type of Provider:

NPI:

Primary Office Address:

Mailing Address (if different from business address):

City: State: Zip Code:

Date and State of Incorporation or Registration:

List all other states in which applicant is approved to conduct external reviews:

Length of time in business with this legal name and Tax ID:

Credentialing Contact Name:

Year Applicant Opened:

Address (If different from above):

Phone: Fax: Email:

Applicant Owner/Parent Company:

Type of Entity (Check one): Corporation Partnership Limited Liability Company Joint Venture Other

List all memberships in professional organizations and trade associations:

Medical Director

Name (Last, First, Middle):

Degree: Specialty:

Office Address:

Phone: Fax: Email:

No Medical Director

Provider Practice Information

Name:

Street Address/PO Box:

City: State: Zip Code:

Phone: Fax: Email:

Website:

Primary Contact Name and Title:

Phone: Fax: Email:

Hours of Operation: Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Included in Provider Directory? Yes No

List language and sign language interpreters/contractors:

Is teletype available? Yes No

Federal Tax ID number: NPI: Administrator/Site Manager:

Service Areas (Counties):

Handicapped Access: Yes No On Bus Route: Yes No Number of Beds:

Additional Practice Location

Name:

Street Address/PO Box:

City: State: Zip Code:

Phone: Fax: Email:

Website:

Primary Contact Name and Title:

Phone: Fax: Email:

Hours of Operation: Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Included in Provider Directory? Yes No

List language and sign language interpreters/contractors:

Is teletype available? Yes No

Federal Tax ID number: NPI: Administrator/Site Manager:

Service Areas (Counties):

Handicapped Access: Yes No On Bus Route: Yes No Number of Beds:

Billing Information

To whom shall checks be made payable:

Billing Address (Street/PO Box):

City: State: Zip Code:

Phone: Fax: Email:

Type of Claim Form Used: CMS1500 UB04 UB92 Other

Accreditation Status

Accrediting Agency Name:

Accreditation Status: Accreditation Date:

Have you ever been denied accreditation by any accrediting body? Yes No

If yes, please provide details:

Licensure and Certifications

Medicaid Provider Number and Status:

Medicare Provider Number and Status:

License Number and Status: NA

CLIA Number: NA

Scope of Services

List all services offered (attach separate page if necessary):

Does the Provider have a toll free number? Yes No

If Yes, please provide number:

Is the Provider staffed 24 hours a day? Yes No

Is the Provider part of a national network of providers? Yes No

If Yes, please describe:

Does the Provider accept Worker's Compensation patients? Yes No

What is the accepted age range of the Provider's patients?

Does the Provider subcontract with other Providers? Yes No

If Yes, please provide names, addresses, description of services provided, and a copy of each contract:

Liability Insurance

General Liability Coverage

Name of Carrier: Policy Number:

Street Address/PO Box:

City: State: Zip Code:

Coverage Type: Occurrence Based Claims Based

Effective Date: Expiration Date:

Per Incident: $ Aggregate: $

Professional Liability (Malpractice) Coverage

Name of Carrier: Policy Number:

Street Address/PO Box:

City: State: Zip Code:

Coverage Type: Occurrence Based Claims Based

Effective Date: Expiration Date:

Per Incident: $ Aggregate: $

Staffing

Provide a list of the types, numbers of professional disciplines, licensures and/or certifications represented on the staff:

Provide a list of any special certifications, accreditations, or licensures held by the professional staff of your organization:

Electronic Capabilities

What are the Provider's current electronic capabilities?

What billing and documentation software is the Provider currently using?

What version is the software?

Does the Provider use this to perform eligibility verification? Yes No

Sent in groups (Batch)? Or one at a time (Real Time)?

Does the Provider use this to perform electronic claim submissions? Yes No

Sent in groups (Batch)? Or one at a time (Real Time)?

Does the Provider use Electronic Medical Records (EMR)? Yes No

What is the name of the EMR software?

What version is the EMR?

Is the EMR software compatible with your billing and documentation software? Yes No

Disclosure Questions

Have criminal proceedings ever been initiated against the Provider or its authorized representatives? Yes No

Has the Provider ever been the subject of an investigation or ever been terminated, suspended, sanctioned or otherwise restricted from participating in any private or public program? Yes No

Has the Provider's professional liability coverage ever been restricted, limited, denied, not renewed, or special rated? Yes No

Has the Provider ever been notified that staff information has been reported to the National Practitioner Data Bank, Healthcare Integrity and Protection Data Bank or professional state licensing boards or registries? Yes No

In the last five years, have there been any professional liability suits, or are there currently any pending or threatened suits? Yes No

Is there currently any pending or threatened licensing or disciplinary action against the Provider? Yes No

References

Name: Company:

Address: Phone:

Name: Company:

Address: Phone:

Name: Company:

Address: Phone:

Standard Authorization, Attestation and Release

I am the authorized agent of the Applicant named below and have the authority to execute this document on behalf of the Applicant. I understand that as part of the credentialing application process, all Applicants are required to provide sufficient and accurate information for evaluation of eligibility for participation.

I acknowledge and understand that my cooperation in obtaining information in connection with this application and my consent to the release of information does not guarantee participation.

Authorization of Investigation Concerning Application for Participation.

The following individuals including, without limitation, the Contracting Entity and its representatives are hereby authorized to investigate information concerning this application.

Authorization of Third-Party Sources to Release Information Concerning Application for Participation.

The Applicant hereby authorizes third parties to release information concerning the qualifications of this Applicant and any other information reasonably having a bearing on the Applicant's qualifications.

Release from Liability.

The Applicant hereby releases from all liability and holds harmless any Contracting Entity, its Agents, and any other third party for their acts performed in good faith and without malice.