Provider Credentialing Application - Align Networks

1 (10/24/14) Page 1 of 13 Provider Credentialing Application Key Contact Information (Please supply high level contacts for each of the following areas in your organization): Contracting: Name: _____ Phone: _____Email:_____ Clinical: Name: _____ Phone: _____Email:_____ Billing: Name: _____ Phone: _____Email:_____ Corporate: Name: _____ Phone: _____Email:_____ Credentialing : Name: _____ Phone: _____Email:_____ Scheduling: Name: _____ Phone: _____Email:_____ Corporate/Main Office Information: Address: _____ Phone Number: _____ Fax Number: _____ E-Mail Address: _____ Ownership and Management: Check all that apply: Corporation For Profit Not for profit Partnership Sponsorship Hospital Sole Proprietorship Privately Held Other Organization Facility/ Provider Information - General Information: Facility/ Provider Legal Name: _____ Facility/ Provider DBA (if applicable):_____ Facility/ Provider Tax Identification #:_____ Medicare Provider # (if applicable): _____ Group/Facility NPI #: _____ What type of billing form is utilized by your facility/facilities?

2 UB92/UB04 or HFCA/CMS1500 Pennsylvania Providers Only Is your facility a PA Part A or PA Part B Provider ? (10/24/14) Page 2 of 13 General Information (Continued): Is your Organization a Physician-Owned Facility/Facilities? Yes No Is your Organization part of any Networks ? Yes No (If yes please specify): _____ What is your bill cycle: Daily Weekly Bi-Weekly Monthly Other (please specify): _____ Day of week bills are generated: Mon Tues Wed Thurs Fri Sat Sun Number of Therapists in your organization that are members of APTA: _____ Number of Therapists in your organization that are members of AOTA: _____ Owner Information (*) Are you a Women Owned and Operated Provider (Women s Business Enterprise)?

3 Yes No Are you a Minority Owned and Operated Provider (Minority Business Enterprise)? Yes No (*) Answers to these questions are optional and are included for compliance with Federal Data Collections. Payment Address: (Please provide the following information regarding where your organization s payments are to be mailed) Address: _____ Phone Number:_____ Fax Number: _____ E-Mail Address: _____ Contact Person Name & Title: _____ Phone # for Contact Person: _____ Fax Number for Contact Person: _____ Professional Liability Insurance Coverage- Malpractice Information Self-Insured: Yes No Name of Current Malpractice Insurance Carrier or Self-Insured Entity: _____ Address:_____ Phone Number: _____ Policy Number: _____ Effective Date (MM/DD/YY):_____ Expiration Date (MM/DD/YY):_____ Amount of Coverage Per Occurrence: _____ Amount of Coverage Aggregate: _____ Type of Coverage.

4 Individual Shared (10/24/14) Page 3 of 13 Professional Liability Insurance Coverage- Malpractice Information (Continued): Length of Time with Carrier: _____ Has your facility/facilities had any claims, suits or settlements in the last 5 years? Yes No (If yes, attach details for each claim) To your organization s knowledge, are there any claims that have not been filed; however, you have been notified of the intent to file? Yes No (If yes, attach details for each claim) * Copy of Insurance Coversheet Required. Medicare/Medicaid Provider Information: Is your organization an approved Medicare Provider ? Yes No Medicare Provider #:_____ Is your organization an approved Medicaid Provider ?

5 Yes No Medicaid Provider #_____ Number of Practitioners within the organization with individual Medicare/Medicaid Provider Numbers:_____ *Please include a copy of CMS Certificate for all active Medicare/Medicaid Provider Numbers within your organization Remainder of this page intentionally left blank (10/24/14) Page 4 of 13 Please complete one copy of page 5 for EACH TREATING LOCATION. Make additional copies as needed. applications submitted without fully completing page 5 for each active treating location will be declined. (10/24/14) Page 5 of 13 Individual Treating Location Information ONE COPY OF THIS PAGE MUST BE COMPLETED FOR EACH TREATING LOCATION (Please provide the following information regarding your treating location/locations please make copies if necessary.)

6 Location Name: _____ Address: _____ Phone Number: _____ Fax Number: _____ E-Mail Address: _____ Office Manager Name: _____ Office Manager Phone Number: _____ Office Manager Fax Number: _____ Office Manager E-Mail Address: _____ Services provided (please check all applicable): PT OT DC Aquatic EMG FCE WH WC CHT X-RAY MRI Speech Whirlpool Splinting Wound Care Debridement Vestibular Rehabilitation Lymphedema Acupuncture Massage Job Site Assessment Ergonomic Assessment CARF Certification (provide copy of certification) Is this location Spanish Speaking? Yes No If any other languages are spoken please specify: _____ Is this location Handicap Accessible? Yes No Does your Facility Offer Complimentary transportation for patients: Yes No Location Hours Patients Are Seen (please include evenings and weekends if applicable): Sunday Monday Tuesday Wednesday Thursday Friday Saturday Remainder of this page intentionally left blank (10/24/14) Page 6 of 13 Please complete one copy of pages 7-10 for EACH LICENSED PT / OT / DC / LAC / SLP PRACTITIONER.

7 Make additional copies as needed. applications submitted without fully completing pages 7-10 for each PT/OT/DC/LAC/SLP practitioner will be declined. Page 10 must be signed by the practitioner and may NOT be signed on his/her behalf by another party or representative. (10/24/14) Page 7 of 13 Individual Practitioner Information Pages 7-10 PLEASE INCLUDE INFORMATION FOR ALL THERAPISTS, DCs and/or LACs AT ALL LOCATIONS. Each Practitioner will need to complete the following: Practitioner Information ( ), Work History ( ) Disclosure Questions ( ), Standard Authorization & Release ( ) portions of the Application . Standard Release must be signed by the individual practitioner. Practitioner Name: _____ Maiden Name (if applicable):_____ Other Name (if applicable):_____ Date of Birth (MM/DD/YYYY):_____ Professional Degree: _____ Issuing Institution: _____ Address of Issuing Institution: _____ Degree: _____ Attendance Dates (MM/DD/YYYY to MM/DD/YYYY) _____ Post-Graduate Education: Internship Residency Fellowship Teaching Appointment Specialty: _____ Institution: _____ Address of Institution: _____ Program Completed: Yes No Attendance Dates (MM/DD/YYYY to MM/DD/YYYY) _____ Program Director: _____ Current Program Director (if known) _____ License Type: _____ License Number: _____ State of Registration: _____ Original Date of Issue (MM/DD/YYYY) _____ Expiration Date (MM/DD/YYYY) _____ Specialty.

8 _____ National Board Certification: Yes No (if yes please indicate below) CCS OCS PCS ECS GCS SCS WCS NCS CHT Board Certification Date (MM/DD/YYYY) _____ Recertification Date (MM/DD/YYYY) _____ National Provider Identifier Number NPI # (when available): _____ Are you a participating Medicare Provider ? Yes No Medicare Provider Number: _____ Are you a participating Medicaid Provider ? Yes No Medicaid Provider Number: _____ Workers Comp Experience: _____ Do you have individual Professional Liability Insurance Coverage (Malpractice)? Yes No If yes please provide a copy with your Credentialing Application (10/24/14) Page 8 of 13 Professional Work History - Please provide practice history, including month and year, for the past FIVE (5) years.

9 An explanation is required for any gap of six (6) months or longer that appear in your Professional Work History. If you completed your professional education and training within the past five (5) years, the work history must cover the time since then. Please make copies if additional space is needed. Practitioner Name: _____ Current Institution/Facility Name: _____ Address: _____ Dates of Affiliation: From (MM/DD/YY):_____ To: (MM/DD/YY):_____ Title: _____ Previous Institution/Facility Name: _____ Address: _____ Dates of Affiliation: From (MM/DD/YY):_____ To: (MM/DD/YY):_____ Title: _____ Previous Institution/Facility Name: _____ Address: _____ Dates of Affiliation: From (MM/DD/YY):_____ To: (MM/DD/YY):_____ Title: _____ Gaps in work history greater than six (6) months?

10 Yes No If yes, please describe. _____ _____ _____ _____ _____ _____ _____ _____ PLEASE ALSO ATTACH A COPY OF YOUR CURRENT CURRICULUM VITAE (10/24/14) Page 9 of 13 Disclosure Questions Practitioner Name: _____ Medicare, Medicaid or other Governmental Program Participation: 1. Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs? Yes No Other Sanctions or Investigations: 2. Are you currently or have you ever been the subject of an investigation by any licensing authority, education or training program, Medicare or Medicaid program, or any other private, federal or state health program?