Initial Credentialing Application Checklist - Cal Care IPA

1 Initial Credentialing Application Checklist If you are a CAQH (Council for Affordable Quality Healthcare) provider please provide your CAQH number CAQH#: _____ California Participating Physician Application (CPPA) P lease ensure the entire Application is completed in its entirety and the Attestation Questions page and Information Release/Acknowledgements page has a current date Addendum A, completed, signed and dated Addendum B, completed, signed and dated. Attach copies of malpractice claims history and explanation in the providers own words, if applicable Addendum C Provider Health History, completed, signed and dated.

2 Medi-Cal # required Addendum D PPMC Provider Rights/Responsibilities form Addendum E, Provider Care Experience, completed, signed and dated Addendum F, HIV Attestation, Only applicable for Internal Medicine and Infectious Disease Provider Addendum G, PPMC Provider Work History Form or Page 6 of the Application (Explanation for any gap of 6 months or greater)(Document dates at mm/yyyy). Additional Information / Documents Required Current copy of California Medical license. Cannot accept expired certificate Current copy of DEA Certificate with CA address/No PO Box, if applicable.

3 Cannot accept expired certificate Current copy of Malpractice Insurance. Must have coverage amounts on certificate. Minimum Aggregate $1 million/$3 million. For mid-levels (PA or NP) must include endorsement Current Curriculum Vitae *Please note the CV on the Application is not acceptable Care 1st SNP Model of Care (MOC) Addendum (All Groups) Special Programs Certificate (CCS, CHDP, CPSP). Include the Certificate or letter Physician Extenders (PA, NP) Signed Supervising Physicians Responsibility General Practitioner only 50 CMEs (within the last 3 years) Staff Roster (affiliated physicians within the office location) Contract Front and Signature Page (if being added to an existing contract) If you have any questions, please contact our office at (951) 280-7700 and ask for the Credentialing Department Completed by: _____ Date.

4 _____ 20160401A-KHPV California Participating Physician Application - 05/97 Page 1 of 10 CONFIDENTIAL/PROPRIETARY California Participating Physician Application This Application is submitted to: PRIMARY PROVIDER MANAGEMENT COMPANY, INC , here in, this Healthcare Organization I. INSTRUCTIONS: This form should be ty ped or legibly printe d in black or blue ink. If more space is needed than pro vided on original, attach additional sheets and re fere nce the questi on being answere d. Please do not use abbreviations when completing the Application .

5 Current copies of th e fo llowing documents must be submitted with th is Application : State Medical License(s) Face Sheet of Pro fessional Liability Policy or Certification DEA Certificate Curriculum Vitae Board Certification (if applicable) ECFMG (if applicable) II. IDENTIFYING INFORMATION Last Name: First: Middle: Is there any other name under which you have been known?

6 Name (s): Home Mailing Address: City: Stat e: ZI P: Home Telephone Number: ( ) Home Fax Number: ( ) E-Mail Address: Pager Number: ( ) Birth Date: Birth Place (City/Stat e/Country): Citizenship (If not a United Stat es citizen, please include copy of Alien Registration Card ). Social Security #: Gender: Male Female Specialty: Race/Ethnicity (v oluntary): Subspecialties: III. PRACTICE INFORMATION Practice Name (if applicable): Department Name (If Hospital Based): Primary Office Street Address: City: Stat e: ZI P: Telephone Number: ( ) Fax Number: ( ) Office Manager/Administrator: Telephone Number: ( ) Fax Number: ( ) Name Affiliated with Tax ID Number: Federa l Tax ID Number: California Participating Physician Application - 05/97 Page 2 of 10 Secondary Office Street Address: City: Stat e: ZI P: Office Manager/Administrator: Telephone Number: ( ) Fax Number: ( ) Name Affiliated with Tax ID Number.

7 Federa l Tax ID Number: Tertiary Office Street Address: City: Stat e: ZI P: Office Manager/Administrator: Telephone Number: ( ) Fax Number: ( ) Name Affiliated with Tax ID Number: Federa l Tax ID Number: Other Medical In terests in Practice, Research, etc.: IV. PREMEDICAL EDUCATION (Attach additional sheets if necessary. Reference This Section Number and Title) College or University Name: Degre e Received: Date of Gra duation: (mm/yy) Mailing Address: City: Stat e: ZI P: V. MEDICAL/PROFESSIONAL EDUCATION (Attach additional sheets if necessary. Reference This Section Number and Title) Medical School: Degre e Received: Date of Gra duation: (mm/yy) Mailing Address: City: State & Country: ZI P: Medical/Pro fessional School: Degre e Received: Date of Gra duation: (mm/yy) Mailing Address: City: State & Country: ZI P: POSTGRADUATE TRAINING AND EXPERIENCE VI.

8 INTERNSHIP/PGYI (Attach additional sheets if necessary. Reference This Section Number and Title) In sti tution: Pro gra m Director: Mailing Address: City: State & Country: ZI P: Type of In ternship : Specialty: From: (mm/yy) To: (mm/yy California Participating Physician Application - 05/97 Page 3 of 10 VII. RESIDENCIES/FELLOWSHIPS (Attach additional sheets if necessary. Reference This Section Number and Title) Include residencies, fellowships, preceptorships, teaching appointments (indicate whether clinical or academic), and postgraduate edu- cation in chronological order, giving name, address, city and ZIP code, and dates.)

9 Include all programs you attended, whether or not completed. In sti tution: Pro gra m Director: Mailing Address: City: Stat e: ZI P: Type of Tra ining (eg. re sidency, etc.): Specialty: Fro m: (mm/yy) To: (mm/yy) Did you successfully complete the pro gra m? Yes No (If "No," please explain on separa te sheet.) In sti tution: Pro gra m Director: Mailing Address: City: Stat e: ZI P: Type of Tra ining: Specialty: Fro m: (mm/yy) To: (mm/yy) Did you successfully complete the pro gra m? Yes No (If "No," please explain on separa te sheet.) In sti tution: Pro gra m Director: Mailing Address: City: Stat e: ZI P: Type of Tra ining: Specialty: Fro m: (mm/yy) To: (mm/yy) Did you successfully complete the pro gra m?

10 Yes No (If "No," please explain on separa te sheet.) VIII. BOARD CERTIFICATION In clude certifications by board (s) which are duly organized and recognized by: a member board of the American Board of Medical Specialties a member board of the American Osteopathic Association a board or association with equivalent re quirements approved by the Medical Board of Californ ia a board or association with an Acc re ditation Council for Gra duate Medical Education of American Osteopathic Association appro ved postgra duate training that pro vides complete training in that specialty or subspecialty Name of Issuing Board.