Map 811 PDF Details

When you are starting a new construction project, there are many forms and permits that you will need to submit in order to get started. One of the most important is the Map 811 Form. This form is used to map out your construction site and ensure that all of the necessary permits have been obtained. Here's what you need to know about the Map 811 Form.

Below is the information regarding the PDF you were seeking to complete. It will show you the time you will need to fill out map 811, exactly what fields you will have to fill in and some additional specific facts.

QuestionAnswer
Form NameMap 811
Form Length15 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 45 sec
Other namesform map 811, map 811 application, kentucky map 811 online, map 811 enrollment form

Form Preview Example

MAP-811Checklist

NOTICE: Pursuant to 907 KAR 1:672 Section 2 1(c) (1), you must be enrolled as a participating provider prior to being eligible to receive reimbursement. Enrollment in the program is not a guarantee; therefore, providing services to

Kentucky Medicaid members prior to your effective date is at your own financial risk.

A complete list of enrollment requirements for each provider type can be found on our website at the following link: https://chfs.ky.gov/agencies/dms/dpi/pe/Pages/prov-summaries.aspx

Did you:

Complete all questions? Questions not applicable should be completed with “N/A”.

(Applications will be rejected for any questions left blank.)

Sign and date signature page (page 12) Electronic or stamped signatures are not accepted.

Attach appropriate licenses and/or certifications and all other required documents for requested effective date as well as current?

Attach verification documentation for NPI and Taxonomy Code(s) from CMS NPI vendor or NPPES.

Attach a MAP-347 if individual wants to be linked to group KY Medicaid provider number.

Attach a copy of your Social Security card if you are enrolling as an individual. Attach your IRS verification letter if you are applying with a FEIN.

If you are subject to an application fee, please attach a check payable to the KY State Treasurer. For more information on the application fee, please refer to your Provider Type Summary at https://chfs.ky.gov/agencies/dms/dpi/pe/Pages/prov-summaries.aspx.

Keep a copy of the application for your records.

Not completing these reminders will delay the processing of your application. Please ensure that all reminders above are completed. Other information not mentioned above may be requested during the processing of your application.

If you are completing this application for ENROLLMENT and you will not be participating with a MCO, please send this application to the following address:

Kentucky Medicaid

P.O. Box 2110

Frankfort, KY 40602

Providers may submit the Medicaid enrollment packet (MAP-811 and all required documentation) to one MCO for processing simultaneous with that MCO’s contract and credentialing application process, in lieu of sending it directly to Medicaid.

Please do not send the application directly to the Department for Medicaid Services. This will delay the processing of your application.

If you have any questions regarding your enrollment, please call Kentucky Medicaid toll free at (877) 838-5085. A provider enrollment specialist will be available to help you between the hours of 8 am and 4:30 pm, EST, Monday through Friday.

MAP-811 Provider Application Instructions

Section A: Administrative Information

Enrollment Block:

If applying for a Kentucky Medicaid number for the first time, check first block.

If reapplying as a Kentucky Medicaid number, check second block and enter your provider number in question #1.

If a change in ownership has occurred, check third block.

If applicant has been excluded from Medicare/Medicaid by Federal, State, or court sanction and has been terminated as a result, please declare “I am enrolling as a reinstatement” by checking fourth block.

MCO Participation: If you will be participating with a KY Managed Care Organization (MCO), please indicate.

Field # Description

1If a Kentucky Medicaid provider number has already been assigned to this provider, enter provider number.

2Please mark the appropriate box. Indicate name of individual provider or if an entity/group is enrolling, please input entity/group name. For individual applicants, the name referenced in this field, must match all supporting documentation. Please include all suffixes in name if applicable. For entity/group applicants, the name referenced in this field and/or in question #3 must match all supporting documentation.

3Enter the name the provider will be doing business as, if different than question #2. Otherwise, you may enter N/A. If you are applying for an individual provider number, do not enter your employer’s name in this field. Enter the provider/Owner Email

4Please mark the appropriate block.

5Please mark the appropriate block.

6Enter License/Certificate number for the applicant. Attach a copy of your license.

7Enter provider type. (EXAMPLE: physician; dentist; etc.) A complete listing of provider types can be found at https://chfs.ky.gov/agencies/dms/dpi/pe/Pages/prov-summaries.aspx.

8Enter the type of service that will be provided. (EXAMPLE: Acute care; diabetic supplies; etc.); Telehealth response

required: Yes/No.

9Enter the date you wish your enrollment with Medicaid to be effective. Date must be in mm/dd/yyyy format.

10Enter your National Provider Identifier (NPI). Include verification email or National Plan and Provider Enumeration System (NPPES) printout.

11Enter your Taxonomy Code(s) associated with your NPI. (Attach extra sheet if necessary.) Include your email verification or NPPES printout.

12Enter individual Social Security Number (SSN).

13Enter FEIN only if you own the FEIN 100%.

14Enter date of birth of applicant provider.

15Please indicate which number will be used for reporting monies to you from Medicaid for 1099 purposes. Example: If you are an individual provider completing this question, please input your SSN or a FEIN if you own the FEIN 100%. If you are applying as an individual and want your monies to go to the entity/group, the individual must complete a MAP- 347 form in order to be linked to the group setting under which they are reporting.

16Please mark the appropriate box for tax structure.

17Enter the first and last name of the person to sign for a summons in case of a lawsuit (N/A is not acceptable).

18Enter telephone number of person named in question #17.

19Enter Physical address, physical county phone, fax,

20Enter Mailing address and credentialing contact information. The field must be completed with an email address.

21Enter Pay-to/1099 address.

22If you have held any Kentucky Medicaid group/facility numbers in the past three years, please enter on form. If not, please indicate with N/A.

23Please list all Medicare numbers of applicant.

24Please complete bed breakdown of facility.

25Enter the Administrator’s name with telephone and fax number.

26Enter the Assistant Administrator’s name, telephone number, and fax number.

27Enter the Controller’s name, telephone number, and fax number.

28Enter the Accountant or CPA’s name, telephone number, and fax number.

29Enter the Fiscal Year End (FYE).

30Complete if you wish to link to a group. Attach a MAP-347 for any additional group you wish to link to.

Section B: Disclosure of Ownership and Control Interest

Field #

Description

1If there has been a change of ownership, list previous Medicaid provider number(s) and start and end dates for each.

2Describe relationship or similarities between the provider disclosing information on this form and items “A” through “C”.

3Do you plan to have a change in ownership, management company or control within the next year? If so, when?

4Do you anticipate filing bankruptcy? If so, when?

5Enter the Federal Tax Identification Number (if there is an affiliation with a chain) along with name, address, city, state and zip code.

6List name, address, SSN/FEIN of each person or organization having direct or indirect ownership or control interest in the disclosing entity. Complete question #7 with the officers’ and board members’ information. If no one owns 5% or more of provider, check box and complete question #7 with the officers’ and board members’ information. If you are applying as an individual and do not own a FEIN, please enter your name and information. In addition, all business locations of the corporate entity must be disclosed.

Indirect Ownership Interest - means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.

Ownership interest - means the possession of equity in the capital, the stock, or the profits of the disclosing entity. Person with an ownership or control interest - means a person or corporation that:

Has an ownership interest totaling 5% or more in a disclosing entity;

Has an indirect ownership interest equal to 5% or more in a disclosing entity;

Has a combination of direct and indirect ownership interests equal to 5% or more in a disclosing entity;

Owns an interest of 5% or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5% of the value of the property or assets of the disclosing entity;

Is an officer or director of a disclosing entity that is organized as a corporation; or,

Is a partner in a disclosing entity that is organized as a partnership

7

List officers’ and board members’ information of disclosing entity. A social security number of officer or board member may be required.

Subcontractor- means an individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients, OR an individual, agency or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or lease of real property) to obtain space, supplies, equipment or services provided under the Medicaid agreement

8

9

10

If applicant is related to persons listed in questions #6, #7, and #17, list the relationship.

List name of managing company, if not applicable enter N/A. A FEIN may be required.

List names of the disclosing entities in which persons have ownership of other disclosing entities.

Other Disclosing Entity- means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under Title V, XVIII, or XX of the Act. This includes:

Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (Title XVIII).

Any Medicare intermediary or carrier.

Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under Title V or Title XX or the Act.

11If entity engages with subcontractors (such as physical therapist, pharmacies, etc.,) which exceeds the lesser of $25,000 or 5% of applicant’s operating expense, list subcontractor’s name and address.

Significant Business Transaction- means any business transaction or series of transactions that, during any one fiscal year, exceeds the lesser of $25,000 or 5% of applicant’s operating expense.

12

13

14

15

Reserved for Future Use.

List name, SSN, address of any immediate family member who is authorized to prescribe drugs, medicine, devices or equipment.

List the name of any individuals or organizations having direct or indirect ownership or controlling interest of 5% or more who have been convicted of a criminal offense related to the involvement of such persons or organizations in any problem established under Title 19 (Medicaid) or Title 20 (Social Services Block Grants) of the Social Security Act (SSA) or any criminal offense in this state or any other state since the inception of those programs. Please also indicate any KY Medicaid provider number(s) associated with individual or organization.

List any agent and/or managing employee who has been convicted of a criminal offense related to any program established under Title XVIII, XIX or XX of the SSA or any criminal offense in this state or any other state since the inception of those programs. Indicate any KY Medicaid provider number(s) associated with individual or organization.

Agent- means any person who has been delegated the authority to obligate or act on behalf of a provider.

Managing Employee- means a general manager, business manager, administrator, director or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization or agency.

16

17

List the name, title, SSN, and business address of all managing employees as defined in 42 CFR 455.101.

List name, address and SSN/FEIN of each person with an ownership or control interest in any subcontractor in which the disclosing entity has direct or indirect ownership of 5% or more.

MAP-811 (Enrollment) (Rev. 03 2019)

COMMONWEALTH OF KENTUCKY

DEPARTMENT FOR MEDICAID SERVICES

SECTION A: ADMINISTRATIVE INFORMATION

For Kentucky Medicaid Use Only

ATN#_____________________

Identifier: __________________

Provider Type _____________

Reviewer’s Initials: ____________

I am enrolling as a:

New Provider

Re-applicant

 

Change of Ownership

Reinstatement

Will you be contracting with a KY Managed Care organization (MCO)? Yes

No If yes, please indicate which MCO?

 

 

Aetna Better Health of KY

Anthem

Humana CareSource

Passport Health Plan

 

WellCare of Kentucky

1.

Kentucky Medicaid Provider Number:

 

 

 

 

 

Check here for N/A

 

(Complete only if you have indicated Reapplicant, or Reinstatement above.)

 

 

 

 

 

 

 

2.

Applying As: Please check only one box and print clearly. For individual applicants,

 

 

Teaching Facility (PT 01 or 02)

please input any suffixes if applicable.

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

Individual

 

 

 

 

 

 

 

 

 

 

Entity

Group

 

 

 

Last:

 

 

 

First:

 

 

MI:

 

Name:

 

 

 

 

 

 

 

3.

Doing Business As (DBA):

 

 

 

 

 

 

 

 

Provider/Owner Email:

 

 

4.

Please select:

Public

Private

 

 

 

 

5. Please select:

Profit

 

 

Non-Profit

6.

 

License/Certification #:

 

 

 

 

 

7. Provider Type:

 

 

 

 

 

 

 

8.

 

Type of Service:

 

 

 

 

 

 

 

9. Date Provider Requests Effective Enrollment: ____/____/_____

Provide Telehealth Services?

Yes

No

 

 

(Date must be in mm/dd/yyyy format.)

 

 

10.

National Provider Identifier (NPI):

 

 

 

11. Primary Taxonomy Code: (Attach extra sheet if necessary. Must match

 

 

 

 

 

 

 

 

 

 

NEPPS)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

SSN:

 

 

 

13. FEIN (Please list

only if you own the FEIN 100%):

 

14. Date of Birth:

 

 

 

 

 

15.

DMS will report all monies paid to the IRS. Please indicate which number you use for tax reporting. (If you are

enrolling as an individual and do not own a FEIN, please check SSN field). (Check one only.)

SSN

FEIN

16.

Tax Structure: Please select only one structure.

 

 

 

 

 

 

 

 

 

 

 

Individual

 

Partnership

 

Corporation

 

 

Government/Non-Profit

 

 

Sole Proprietor

 

Estate/Trust

 

Public Service Corporation

Limited Liability Company

17.

Agent of Service in Case of Summons (N/A not acceptable).

 

 

18. Telephone # of Agent of Service

First Name:

 

 

 

Last Name:

 

 

 

 

 

 

(N/A not acceptable).

 

19.

PRIMARY PHYSICAL BUSINESS LOCATION:

 

 

 

 

 

 

 

 

 

(If you have more than one physical location, attach a copy of items listing additional locations. If an entity/group is applying, each additional location may require separate enrollment.)

Street Address:

City:

 

 

 

 

 

 

State:

Zip:

Phone #:

Ext.

 

Fax #:

 

County

:

 

 

 

 

 

20.

MAILING ADDRESS:

(Check here if same as primary physical business address)

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

State:

 

 

Zip:

Credentialing Contact Information (Required)

 

 

 

 

 

 

 

 

(This individual will be contacted should any information be needed to process the application.)

Note: Your email address will

not be given to any outside party for any reason. DMS may use provider email addresses to send provider letters/notices.

Name:

 

 

 

 

Email Address:

 

 

 

Phone:

 

 

 

 

Fax Number:

 

 

 

21.

PAY-TO/1099 ADDRESS:

(Check here if same as primary physical business address)

 

 

 

Address :

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

State:

 

 

Zip:

Contact First Name:

 

 

Contact Last Name:

 

 

 

 

Phone #:

 

22.

List any Kentucky Medicaid group/facility numbers you have held in the past three years.

Check here for N/A

 

 

23.

Please list all Medicare Provider Numbers. (Attach extra sheet if necessary.) Check here for N/A

Fill out all Applicable Sections. Write Not Applicable (N/A) for questions that do not apply. Applications will be rejected for any questions left blank. Please

print or type. Reformatted or altered applications will not be accepted.

- 1 -

MAP-811 (Enrollment) (Rev. 03 2019)

24. Bed Breakdown Check here for N/A

 

 

 

_________ Acute

_________ TCU

_________ Hosp. Swing

_________ ICF/IID

_________ ICU

_________ Nursery

_________ Rehab. Hosp.

_________ Ventilator Unit

_________

Surgical ICU

_________ Neonatal ICU

_________

Psych. Hosp.

_________ Brain Injury

_________

Burn ICU

_________ CCU

_________

PRTF

Unit

_________ NF/Medicaid

_________ NF (Medicare/Medicaid)

 

 

 

 

 

 

 

 

 

_________ Other /specify:

 

 

 

 

 

 

 

 

 

 

25.

Administrator:

 

 

 

 

Phone:

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here for N/A

 

 

 

 

 

 

 

 

 

 

26.

Assistant Administrator:

 

 

 

Phone:

 

 

Fax:

Check here for N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27.

Controller:

 

 

 

Phone:

 

 

Fax:

Check here

for N/A

 

 

 

 

 

 

 

 

 

 

28.

Accountant or CPA:

 

 

 

Phone:

 

Fax:

Check here for N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29.

Fiscal Year End Date (FYE):

 

 

 

 

Check here for N/A

30.If you are applying as an individual, please complete if you wish to link to a Clinic Corporation or Facility. Check here for N/A

I hereby declare that I

(Individual Provider Enrolling)

have entered into a contractual agreement with the following:

(Clinic/Corporation or Facility Name)

(KY Medicaid Provider Number of Clinic/Corporation or Facility)

to provide professional services. I authorize payment including Medicaid/Medicare cross-overs, from the Kentucky Medicaid Program for covered services provided by me and specified by the criteria of our contract. I understand that I, personally shall not bill the Kentucky Medicaid Program for any service that is reimbursed as part of contractual agreement, and further that Clinic/Corporation or Facility Name listed above shall be responsible for refunding any overpayments made for services rendered. (Please note: If you choose to link to more than one group please attach a MAP-347).

Fill out all Applicable Sections. Write Not Applicable (N/A) for questions that do not apply. Applications will be rejected for any questions left blank. Please

print or type. Reformatted or altered applications will not be accepted.

- 2 -

MAP-811 (Enrollment) (Rev. 03 2019)

SECTION B: DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST

SECTION B IS REQUIRED BY FEDERAL AND STATE LAW AND REGULATION (42 CFR 455.101, 455.104, 455.105 AND 455.106 and KRS CHAPTER 205, AS AMENDED).

Note: See the instructions for definitions of underlined terms per 42 CFR 455.101 and 455.104 and KRS Chapter 205, as amended.

(Any attachments must be labeled referencing the question.)

1.If there has been a change in ownership, enter the previous provider number(s) and their effective date(s): Check here for N/A

Previous Medicaid Prov. #

Start Date:

to End Date:

2a. If you completed question #1 above, describe the relationship between the owner disclosing information on this form and the previous Medicaid owner. (Attach extra page if necessary.) Check here for N/A

2b. If you completed question #1 above, describe the relationship between the corporate boards of disclosing provider and previous corporate boards of Medicaid provider. (Attach extra page if necessary.)

2c. Why did a change of ownership occur?

3.If you anticipate any change of ownership, management company or control within the year, state anticipated date of change and nature of the change. Check here for N/A

Date:Change:

4.

If you anticipate filing for bankruptcy within the year, enter anticipated date of filing. Date:

Check here for N/A

5.

If this facility is a subsidiary of a parent corporation, enter corporate FEIN #:

Check here for N/A

Name:

 

 

Box or Address:

 

 

City:

State:

Zip:

6. List name, date of birth, SSN#/FEIN#, and address of each person or entity that owns 5% or more direct or indirect

ownership or controlling interest in the applicant provider.

(Attach extra page if necessary.)

(N/A not acceptable.) . If you

are applying as an individual, list your information.

Check here if no one owns 5% or more.

Name:

 

SSN:

 

 

Business Address:

 

FEIN:

 

DOB:

City:

 

State:

 

Zip:

P.O. Box:

 

 

 

 

City:

 

State:

 

Zip:

**IF A CORPORATE ENTITY IS DISCLOSED IN QUESTION #6 ABOVE, THE BUSINESS LOCATIONS OF THE CORPORATE ENTITY MUST BE DISCLOSED. PLEASE ATTACH A SHEET TO DISCLOSE THIS INFORMATION.

7. List officers’ and board members’ information of disclosing entity. (Attach extra sheet if necessary, listing same details

below.)

Check here for N/A *The entire first name is required. Initials are not accepted.

Name (a):

Address:

City:

Name (b):

Address:

City:

Title:

SSN:

State:Zip:

Title:

SSN:

State:Zip:

Fill out all Applicable Sections. Write Not Applicable (N/A) for questions that do not apply. Applications will be rejected for any questions left blank. Please

print or type. Reformatted or altered applications will not be accepted.

- 3 -

MAP-811 (Enrollment) (Rev. 03 2019)

8.If any individuals listed in questions #6, #7, and #17 are related to each other as spouse, parent, child, or sibling (including step or adoptive relationships), provide the following information: (Attach extra page if necessary.) Check here for N/A

Name(a):

Relationship:

Name(b):

Relationship:

SSN:

FEIN:

SSN:

FEIN:

9.If this facility employs a management company, please provide following information: Check here for N/A Name:

Address:

City:

State:

Zip:

10.List the name of any other disclosing entity in which an owner of the disclosing entity has an ownership or control interest. Check here for N/A

Name:

Address:

City:

Provider Number:

State:

Zip:

11.List the names and addresses of all other Kentucky Medicaid providers with which your health service and/or facility engages in a significant business transaction and/or a series of transactions that during any one (1) fiscal year exceed the

lesser of $25,000 or 5% of your total operating expense. (Attach extra page if necessary.)

Check here for N/A

Name:

Address:

City:

State:

Zip:

12.Reserved for Future Use.

13.List the name, SSN, and address of any immediate family member who is authorized under Kentucky Law or any other states' professional boards to prescribe drugs, medicine, medical devices, or medical equipment in accordance with KRS 205.8477. Check here for N/A

Name (a):

Address:

City:

Name (b):

Address:

City:

Credential (M.D., etc.):

DOB:SSN:

State: Zip:

Credential (M.D., etc.):

DOB:SSN:

State: Zip:

14.List the name of any individuals or organizations having direct or indirect ownership or controlling interest of 5% or more, who have been convicted of a criminal offense related to the involvement of such persons, or organizations in any program established under Title XVIII (Medicare), or Title XIX (Medicaid), or Title XX (Social Services Block Grants) of the Social Security Act or any criminal offense in this state or any other state, since the inception of those programs. (Attach extra page if necessary.) If individual or organization is associated with a KY Medicaid provider number(s), please indicate

below. (Attach extra page if necessary.)

Check here for N/A

NAME (a)/KY Medicaid Provider Number(s):

NAME (b)/KY Medicaid Provider Numbers(s):

15.List the name of any agent and/or managing employee of the disclosing entity who has been convicted of a criminal offense related to the involvement in any program established under Title XVIII, XIX, or XX, or XXI of the Social Security Act or any criminal offense in this state or any other state since the inception of those programs. (Attach extra page if necessary.) If individual or organization is associated with a KY Medicaid provider number(s), indicate below. (Attach extra page if necessary.) Check here for N/A

NAME (a)/KY Medicaid Provider Number(s): NAME (b)/KY Medicaid Provider Number(s):

Fill out all Applicable Sections. Write Not Applicable (N/A) for questions that do not apply. Applications will be rejected for any questions left blank. Please

print or type. Reformatted or altered applications will not be accepted.

- 4 -

MAP-811 (Enrollment) (Rev. 03 2019)

16.List the name, title, SSN, and business address of all managing employees below as defined in 42 CFR 455.101. Check here for N/A (Attach extra sheet if necessary listing same details below.)

Name (a):

Box or Address:

City:

Name (b):

Box or Address:

City:

Credential (M.D., etc.):

DOB:SSN:

State: Zip:

Credential (M.D., etc.):

DOB:SSN:

State: Zip:

17.List name, address, SSN#, FEIN# of each person with an ownership or control interest in any SUBCONTRACTOR in which the provider applicant has direct or indirect ownership of 5% or more. (Attach extra page if necessary.)

Check here for N/A

Name(a):

Box or Address:

City:

Name(b):

Box or Address:

City:

SSN:

FEIN:

State: Zip:

SSN:

FEIN:

State: Zip:

Fill out all Applicable Sections. Write Not Applicable (N/A) for questions that do not apply. Applications will be rejected for any questions left blank. Please

print or type. Reformatted or altered applications will not be accepted.

- 5 -

MAP-811 (Enrollment) (Rev. 03 2019)

SECTION C: ATTESTATIONS

(TO BE COMPLETED IF ENROLLING AS AN INDIVIDUAL PROVIDER. DO NOT COMPLETE IF ENROLLING AS A GROUP OR ENTITY.)

Please answer all questions. For any “Yes” response, please attach an explanation.

1. LICENSURE

YES

NO

a.

Has your license, registration or certification to practice in your profession, ever been voluntarily or

 

 

 

involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine,

 

 

 

reprimand, consent order, probation or any conditions or limitations by any state or professional licensing,

 

 

 

registration or certification board?

YES

NO

b.

Has there been any challenge to your licensure, registration or certification?

2. HOSPITAL

PRIVILEGES AND OTHER AFFILIATIONS

YES

NO

a.

Have your clinical privileges or medical staff membership at any hospital or healthcare institution, voluntarily

 

 

 

or involuntarily, ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary

 

 

 

or to other disciplinary conditions (for reasons other than non-completion of medical record when quality of

 

 

 

care was not adversely affected) or have proceedings toward any of those ends been instituted or

 

 

 

recommended by any hospital or healthcare institution, medical staff or committee, or governing board?

YES

NO

b.

Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while

 

 

 

under investigation?

YES

NO

c.

Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any

 

 

 

disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations

 

 

 

such as IPAs, PHOs)?

3. EDUCATION,

TRAINING AND BOARD CERTIFICATION

YES

NO

a.

Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during

 

 

 

an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in

 

 

 

a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or

 

 

 

asked to resign

YES

NO

b.

Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely

 

 

 

terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or

 

 

 

other clinical education program?

YES

NO

c.

Have any of your board certifications or eligibility ever been revoked?

YES

NO

d.

Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under

 

 

 

investigation

4. DEA OR STATE CONTROLLED SUBSTANCE REGISTRATION

YES

NO

a.

Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s) or

 

 

 

authorization(s) ever been challenged, denied, suspended, revoked, restricted, denied renewal, or voluntarily

 

 

 

or involuntarily relinquished?

5. MEDICARE,

MEDICAID OR OTHER GOVERNMENTAL PROGRAM PARTICIPATION

YES

NO

a.

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 healthcare plans or programs?

6. OTHER SANCTIONS OR INVESTIGATIONS

YES

NO

a.

Are you currently the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing

 

 

 

entities, education or training program, Medicare or Medicaid program, or any other private, federal or state

 

 

 

health program or a defendant in any civil action that is reasonably related to your qualifications, competence,

 

 

 

functions, or duties as a medical professional for alleged fraud, an act of violence, child abuse or a sexual

 

 

 

offense or sexual misconduct?

YES

NO

b.

To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data

 

 

 

Bank or Healthcare Integrity and Protection Data Bank?

YES

NO

c.

Have you ever received sanctions from or are you currently the subject of investigation by any regulatory

 

 

 

agencies (e.g., CLIA, OSHA, etc.)?

YES

NO

d.

Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted,

 

 

 

disciplined or resigned in exchange for no investigation or adverse action within the last ten years for sexual

 

 

 

harassment or other illegal misconduct?

YES

NO

e.

Are you currently being investigated or have you ever been sanctioned, reprimanded, or cautioned by a

 

 

 

military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation or in

 

 

 

exchange for no investigation by a hospital or healthcare facility of any military agency?

Fill out all Applicable Sections. Write Not Applicable (N/A) for questions that do not apply. Applications will be rejected for any questions left blank. Please

print or type. Reformatted or altered applications will not be accepted.

- 6 -

MAP-811 (Enrollment) (Rev. 03 2019)

7.

PROFESSIONAL LIABILITY INSURANCE INFORMATION AND CLAIMS HISTORY

 

YES

NO

a.

Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier

 

 

 

 

based on your individual liability history?

 

YES

NO

b

Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional

 

 

 

 

liability insurance carrier, based on your individual liability history?

8.

MALPRACTICE

 

CLAIMS HISTORY

YES NO

a.

Have you had any professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past 10 years? * If yes, provide information for each case.

9. CRIMINAL/CIVIL HISTORY

YES

NO

a.

Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony?

YES

NO

b.

In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor

 

 

 

(excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably

 

 

 

related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act

 

 

 

of violence, child abuse or a sexual offense or sexual misconduct?

YES

NO

c.

Have you ever been court-martialed for actions related to your duties as a medical professional?

10. ABILITY TO PERFORM JOB

YES

NO

a.

Are you currently engaged in the illegal use of drugs?

 

 

 

("Currently" means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing

 

 

 

impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks

 

 

 

before the date of application, rather that it has occurred recently enough to indicate the individual is actively

 

 

 

engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful

 

 

 

under the Controlled Substances Act, 21 U.S.C. § 812. It "does not include the use of a drug taken under

 

 

 

supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act

 

 

 

or other provision of Federal law." The term does include, however, the unlawful use of prescription

 

 

 

controlled substances.)

YES

NO

b.

Do you use any chemical substances that would in any way impair or limit your ability to practice medicine

 

 

 

and perform the functions of your job with reasonable skill and safety?

YES

NO

c.

Do you have any reason to believe that you would pose a risk to the safety or wellbeing of your patients?

YES

NO

d.

Are you unable to perform the essential functions of a practitioner in your area of practice even with

 

 

 

reasonable accommodation?

Fill out all Applicable Sections. Write Not Applicable (N/A) for questions that do not apply. Applications will be rejected for any questions left blank. Please

print or type. Reformatted or altered applications will not be accepted.

- 7 -

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