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.

4 _____ Amount of Coverage Aggregate: _____ Type of Coverage: 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 ?

5 Yes No Medicare Provider #:_____ Is your organization an approved Medicaid Provider ? 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.

6 (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.) 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?

7 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.

8 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 .

9 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.

10 _____ Original Date of Issue (MM/DD/YYYY) _____ Expiration Date (MM/DD/YYYY) _____ Specialty: _____ 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)?