Initial Practitioner Credentialing Application Checklist

1 2019 by Blue Cross of idaho , an independent licensee of the Blue Cross and Blue Shield AssociationForm No. 9-203NI (09-19) Initial Practitioner Credentialing Application ChecklistThank you for your interest in Blue Cross of idaho . Use this Checklist to ensure proper completion of the enclosed idaho Practitioner Application September 2019. Completed Application : Ensure all sections of the Application are complete or indicate Does Not Apply as appropriate. Please be aware that referencing Curriculum Vitae (CV) is not an acceptable substitute for completing the Application . Licenses: List all current and expired state professional licenses, including those for idaho (page 2, Section V) DEA Registration: Provide DEA registration information, as applicable (page 2, Section IV) Education: Provide education information, complete with start and end dates (pages 2-4, Section VI, VII, VIII) Certifications: Provide board and any other applicable certification information (page 4, Section XIV).

2 In addition, nurse practitioners and allied health practitioners must provide copies of professional certifications ( , AANP, ANCC, CCNA, CRNA etc.) Hospital Affiliations: List current primary admitting facility along with other current or pending hospital affiliations (page 5, Section XVI) Work History: Provide complete work history and explain lapses for the previous five years or since earning degree (page 6, Section XVII) Liability Insurance: Include copy of current professional liability insurance face sheet showing minimum requirements of $1 million/$3 million in coverage idaho Practitioner Attestation Questions Form: Provide a completed, signed, dated and unaltered copy with written explanation for any Yes answers (pages 9 and 10) Release of Authorization Form: Provide a completed, signed, dated and unaltered copy (page 11)Please note.

3 Your Application information cannot be more than 180 days old at the time of Blue Cross of idaho 's review. On average, our Credentialing process takes 60 to 90 days. Please make sure you provide ample processing time when signing and submitting your Application . We cannot accept or process incomplete or outdated applications . Lack of correct information will delay your ability to contract with Blue Cross of idaho . We accept applications by fax at 208-387-6818 or email to For Credentialing questions, call 208-286-3447.(Revised: 9/2019)3000 E. Pine Avenue, Meridian, ID 83642-5995 Box 7408, Boise, ID 83707-1408 (208) 345-4550 2019 by Blue Cross of idaho , an independent licensee of the Blue Cross and Blue Shield AssociationForm No. 9-203NI (09-19)Applicant Rights for Credentialing and Recredentialing Applicants have the right, upon request, to be informed of the status of their Application .

4 Applicants may contact Credentialing staff by telephone or in writing to ask about the status of their Application . Credentialing staff will respond to the applicant s request for information about their Application status either by telephone or in writing within 15 calendar days. Blue Cross of idaho is not required to provide the applicant with information that is peer-review protected. Information reported to the National Practitioner Data Bank (NPDB) is considered confidential and shall not be disclosed. An applicant will be advised that they may complete a self-query to obtain information that is contained in the NPDB. Applicants have the right to review the information submitted in support of their Credentialing Application . This review is at the applicant s request. The applicant will be notified in writing of Initial Credentialing decisions within 60 days of being reviewed.

5 Credentialing staff will notify the applicant in writing of any information obtained during the Credentialing process that varies significantly from the information provided to Blue Cross of idaho . Should the information provided by the applicant on his or her Application vary substantially from the information obtained and/or provided to Blue Cross of idaho by other individuals or organizations contacted as part of the Credentialing and/or recredentialing process, Credentialing staff will contact the applicant by fax, mail or email to advise the applicant of the variance and provide the applicant with the opportunity to correct the information if it is incorrect. The applicant will submit any corrections in writing within 30 calendar days to the Credentialing staff. Any additional documentation will be kept as part of the applicant s credential E.

6 Pine Avenue, Meridian, ID 83642-5995 Box 7408, Boise, ID 83707-1408 (208) 345-4550 2019 by Blue Cross of idaho , an independent licensee of the Blue Cross and Blue Shield AssociationForm No. 9-203NI (09-19) idaho Practitioner ApplicationFollow these instructions to use the idaho Practitioner Application (IPA): Complete the Application in its entirety using black or blue ink. Keep an unsigned and undated copy of the Application on file for future requests. When a request is received, send a copy of the completed Application , making sure that all information is complete, current and accurate. Please sign and date pages 9 , 10 and 11. Document any "YES" responses on the Attestation Question page. Inquire with the organization prior to submitting this Application to any healthcare-related organization, as you may need authorization (through a pre- Application process) before the Application is accepted.

7 Identify the healthcare related organization(s) to which this Application is being submitted in the space provided below. Attach copies of requested documents each time the Application is submitted. If changes must be made to the completed Application , strike out the information and write in the modification, Initial and date. Check the provided box at the top of the section if a section does not apply to you. Expect addendums from the requesting organizations for information not included on the Application is submitted toI. INSTRUCTIONSThis form should be typed or legibly printed in black or blue ink. If more space is needed than provided, attach additional sheets and reference the question being answered. Please do not use abbreviations. Current copies of the following documents must be submitted with this Application (all are required for MDs, DOs; as applicable for other health practitioners).

8 If not available, indicate why. State Professional License(s) DEA Certificate w/ idaho address ECFMG (if applicable) ISBP Certificate Passport photo (for hospitals only) Face Sheet of Professional Liability Policy or Certificate Curriculum Vitae (Not an acceptable substitute for completing the Application .)** All sections must be completed in their entirety.**II. Practitioner INFORMATIONLast name (include suffix; Jr., Sr., III)First (do not abbreviate)Middle (do not abbreviate)Other name(s) under which you have been known by reference, licensing and or educational institutions?Degree(s)Home telephone numberPager numberCell numberEmail addressHome mailing addressCityStateZIP CodeBirth dateBirth place (city, state, country)Social security numberCitizenshipLanguages spoken by practitionerSpecialty PCP Urgent Care SpecialistGender Male FemaleNPIM edicare UPINM edicare number (ID)Medicaid number(s)Other professional interests in practice, research, PRACTICEINFORMATIONE ffective Date at Primary Practice location Name of practice, affiliation or clinic nameDepartment name (if hospital based)Primary office street addressCityStateZIP CodePatient appointment telephone numberFax numberName affiliated with tax ID numberFederal tax ID numberMailing address (if different from above)

9 CityStateZIP CodeIdaho Practitioner Application September 2019 Page 1 of 11 Practitioner Name Modification to the wording or format of the idaho Practitioner Application may invalidate the Application . 2019 by Blue Cross of idaho , an independent licensee of the Blue Cross and Blue Shield AssociationForm No. 9-203NI (09-19)III. PRACTICE INFORMATION (CONTINUED)Billing address (if different from above)CityStateZIP CodeOffice manager / Administrator nameAdministration telephone numberFax numberE-mail addressCredentialing contact (if different from above) Credentialing telephone numberFax numberE-mail addressEffective Date at Secondary Practice location Secondary office street addressCityStateZIP CodePatient appointment telephone numberFax numberName affiliated with tax ID numberFederal tax ID numberMailing address (if different from above)CityStateZIP CodeBilling address (if different from above)CityStateZIP CodeOffice manager / Administrator nameAdministration telephone numberFax numberE-mail addressCredentialing contact (if different from above)

10 Credentialing telephone numberFax numberE-mail addressList other office locations with above information on a separate PROFESSIONALLICENSUREE ffective Date at Primary Practice location Status PCP Urgent Care SpecialistIssue dateExpiration dateName of sponsor if required by licensure, ( Physician s Assistant).Drug Enforcement Administration (DEA) registration numberIssue dateExpiration dateState controlled substance certificate numberIssue dateExpiration dateECFMG number (applicable to foreign medical graduates)Date issuedV. ALL OTHER PROFESSIONALLICENSESS tateLicense/registration/certificate numberDate IssuedExpiration dateYear relinquishedReasonStateLicense/registrat ion/certificate numberDate IssuedExpiration dateYear relinquishedReasonStateLicense/registrat ion/certificate numberDate IssuedExpiration dateYear relinquishedReasonVI.