HEALTHCARE PRACTITIONERS INSTITUTION/ANCILLARY …

1 Provider Application for Participation (PART 1) Instructions For facilities, institutions and ancillary providers HEALTHCARE PRACTITIONERS If you are a health care practitioner (or group of health care PRACTITIONERS ), licensed, or certified to provide health care services, and are interested in participating in the Kaiser Permanente network, please request the following forms: Provider Application for Participation (Parts 2 & 3) Practice Information and Provider Information. INSTITUTION/ANCILLARY PROVIDERS OF SERVICES If you are a provider of health care services, supplies, or equipment and are interested in participating in the Kaiser Permanente network, please complete and return the attached form: Provider Application for Participation INSTITUTION/ANCILLARY (Part 4), Facility/Group Information.

2 You may include with your application any brochures and/or additional information describing your services. PLEASE RETURN PROVIDER APPLICATION FOR PARTICIPATION TO: Kaiser Foundation health Plan of Colorado Attention: 10350 E. Dakota Ave. Denver, CO 80247 Fax Number: (303) 344-7980 NOTE: If the vendor or group named in this application already has a contract with us, this is the wrong form and it will not be processed! Duplicate, illegible, or incomplete applications will be automatically denied. Within 30 days of receipt of your completed application, Kaiser Permanente will notify you in writing of our decision. If your application is approved, you will be informed of next steps.

3 Please contact our Provider Relations Department at 303-344-7943 for assistance as necessary. DISCLAIMER: All information will be assessed against Kaiser Permanente s network needs. Submission of an application does not constitute any obligation on the part of CPMG, or any other related Kaiser Permanente entities to enter into a contractual relationship with you. Kaiser Foundation health Plan Colorado Permanente Of Colorado, Inc. Medical Group, 09/06/2006 Provider Application for Participation (PART 2) Practice Information Please type or print clearly.

4 All information is required. Illegible or incomplete applications must be automatically denied. For office use only Date Application Received:Group/Practice name:_____ Fed Tax I/D/ Number:_____ NPI Number:_____ Contact Name:_____ Contact Street Address:_____ City:_____ State:_____ Zip:_____ Phone:_____ Fax:_____ Email:_____ Facility Locations: Street Address City State Zip (1) _____ (2) _____ (3) _____ (4) _____ Major Specialty(s) provided (ex: Cardiology, Family Practice, OB/GYN, General Surgery): (1)_____ (2) _____ (3) _____ Foreign language(s) that the Group/Practice are able to treat patients in: (1) _____ (2) _____ (3) _____ Hospital(s) where providers have admitting/staff privileges: (1) _____ (2) _____ (3) _____ Does this Group/Practice: Yes No Currently offer 24/7 coverage?

5 (include all covering providers on Provider Information page) Yes No Maintain general liability insurance at the minimal limits of $1,000,000/$3,000,000? Yes No Have a physical address and location outside your home? Yes No Accept Medicare patients? Yes No Agree to facilitate all necessary credentialing activities? Kaiser Foundation health Plan Colorado Permanente Of Colorado Medical Group, 09/06/2006 Provider Application for Participation (PART 3) Practice Information Please type or print clearly.

6 All information is required. Illegible or incomplete applications must be automatically denied. Provider Name Last name, First name Title Ex: MD, DO NP, LCSW Specialty UPIN/NPI SS# Kaiser Foundation health Plan Colorado Permanente Of Colorado Medical Group, 09/06/2006 Provider Application for Participation (PART 4) Facility/Group Information Please type or print clearly.

7 All information is required. Illegible or incomplete applications must be automatically denied. For office use only Date Application Received: INSTITUTION/ANCILLARY name:_____ Fed Tax I/D/ Number:_____ NPI Number:_____ Contact Name:_____ Contact Street Address:_____ City:_____ State:_____ Zip:_____ Phone:_____ Fax:_____ Email:_____ Facility Locations: Street Address City State Zip (5) _____ (6) _____ (7) _____ (8) _____ Service Provided (check one only): o Inpatient Hospital o Specialty Hospital o Skilled Nursing Facility o Hospice o Ambulatory Surgery Center o Dialysis Center o Urgent care Facility o Durable Medical Equipment o Home health care o Ambulance Kaiser Foundation health Plan Colorado Permanente Of Colorado Medical Group.