CREDENTIALING INFORMATION FORM: Physician

CREDENTIALING INFORMATION FORM: Physician
How did you find out about MD Reimbursement Associates?
First Name*
Middle Name
Last Name*
Degree*
Street Address*
City*
State*
Zip Code:*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date Of Birth*

MonthDayYear
Date
City & Country of Birth*
Professional Data
CAQH ID:
USER ID:
PASSWORD:
PECOS USER ID:
PASSWORD:
State License #*
DEA #*
SSN #*
MEDICAID #*
MEDICARE #*
NPI #*
CDS #*
Primary Specialty:*
Please choose an option*

Board CertifiedBoard Eligible
Name of Certifying Board:*
Date of Certification*

MonthDayYear
Date
Expiration Date*

MonthDayYear
Date
Sub-Specialty:*
Please choose an option*

Board CertifiedBoard Eligible
Name of Certifying Board*
Date of Certification*

MonthDayYear
Date
Expiration Date*

MonthDayYear
Date
Are there any age limitations*

YesNo
Min/Max Age Limitation:*
Do you currently have hospital admitting privileges? (If more than one hospital, indicate primary)*

YesNo
Hospital Name and Address
Covering Provider Information:

Covering providers should be participating providers or be in the process of becoming providers in the plan you are applying to
Provider Name:*
Address:*
City:*
State and Zip Code:*
Phone Number*
Please enter a valid phone number.
Specialty:*
Practice Information
Business Name/ DBA:
Group NPI:
Tax ID:
Group Medicare #:
Group Medicaid #:
How many Practice Locations?
Address:
City, State, Zip:
Contact Name:
Office Phone:
Office Fax:
Started to Work:
Facilities:(include type - skilled nursing, memory care, etc.)

1.
2.
3.
4.
5.
6.
Billing Information:
Make Checks Payable To:
Address:
City/State/Zip:
Contact Name:
Phone:
Fax:
Correspondence Information

Specify address at which insurance can contact the doctor direct, if different from above
Address:
City/State/Zip:
Contact Name:
Phone:
Fax:
Confidential Information:
1. Do you have any history of malpractice action (settlements, judgments, or otherwise)?*

YesNo
2. Do you have any malpractice cases pending?*

YesNo
3. Have you ever been convicted of fraud, narcotics or any other felony offense?*

YesNo
4. Has your license to practice medicine ever been subjected to any revocation, suspension, probation, or other disciplinary action by any state licensing authority or medical society?*

YesNo
5. Have you ever been barred from participation in Medicaid/Medicare programs?*

YesNo
6. Have clinical privileges ever been denied, revoked, suspended or restricted in anyway?*

YesNo
7. Do you have any physical or mental impairment that would cause you to be unable to perform the essential functions in your area of practice, without any threat to the health and safety of others?*

YesNo
8. Are you suffering from any communicable health condition that, considering the essential functions of your practice, could pose a health or safety risk to your patients?*

YesNo
9. Within the past three years have you had any substance abuse, or chemical dependency problems, which might affect your ability to practice medicine in your area of expertise in anyway?*

YesNo
For each question to which you answered YES, please attach an explanation, including without limitation:

1. The incident(s) upon which the action(s) were based, including pertinent dates.
2. How the matter was resolved, including any conditions and whether they have been met or are still pending.
3. List any payments and whether the payments were a result of settlement or judgment.
4. Describe in detail the specific clinical steps or process you instituted to prevent the recurrence of this
5. List any continuing education courses you attended relating to this situation, including dates of attendance.
PLEASE ATTACH COPIES OF THE FOLLOWING, if applicable:

➔   State License

➔   Curriculum Vitae

➔   Medical Liability Insurance Coverage:$⅓ million

➔   IRS Form W-9

➔   Board Certification (if applicable)

➔   Copy of Diploma

➔   Registration and Infection Control Training Certificate

➔   NPI Award Letter (individual and Group)

➔   ECFMG Certificate
File Upload

Cancelof
Signature

Clear
Should be Empty:

CREDENTIALING INFORMATION FORM: Physician

Professional Data

Covering Provider Information:

Practice Information

Billing Information:

Correspondence Information

Confidential Information: