Multiplan Physician Application Form – Fill Out and Use This PDF

Arkansas Preferred Physician Application

Page 1

For MultiPlan Use Only

REGISTRATION INSURANCE LANGUAGES PROF HISTORY CERTIFICATIONS INDICATIVE

ADDRESSES

LAST NAME

FIRST NAME

M.I.

TITLE (e.g., Jr., Sr., III)

*SOCIAL SECURITY NUMBER

*BIRTH DATE (mm/dd/yyyy)

GENDER

–

–

/

/

M

F

E-MAIL_______________________________________

Specialty

Please indicate the specialties in which you would like to receive referrals for new patients.

Primary Specialty

Other

Other

Education

Medical School

City, State

Degree Awarded

MD

■

DO

■

Country

Attended (mm/dd/yyyy)

/

/

/

/

From

To

Please indicate language(s) spoken by provider in addition to English ______________________________________________________________________________

Please indicate if you communicate in Sign Language

■ Yes ■ No

Professional Liability (Malpractice)

Do you intend to maintain your current professional liability insurance limits?

If no, please enclose a detailed explanation. ■ Yes ■ No

Comprehensive General Liability

Carrier

Expiration Date (mm/dd/yyyy)

Levels:

Per Occurrence

In Aggregate

/

/

$

$

DEA Certification

*Do you administer or prescribe controlled substances (Schedule II, III, V medications)?

ARKANSAS STATE MEDICAL BOARD

■ Yes:

DEA Certificate #

–

LICENSE NUMBER:

_______________________________________________

■ No:

I do not administer or prescribe controlled substances; I do not have a DEA number.

Address Information I

•Please provide practice, billing and mailing information for each office in which you see patients under this contract.

•Attach additional sheets if necessary.

Address 1 (Please provide your payment address first. Note: If this is also a practice address, it cannot be a P.O. Box.)

■ Payment Address

■ Practice Address

■ Mailing Address

Street

Suite

City

State

Zip

-

Phone Numbers

Appointments

Billing

–

–

Ext.

–

–

Ext.

Fax

–

–

TAX INFORMATION ADDRESSES

Average Appointment Scheduling Time

New patient __________Hours / Days / Weeks

Routine Visit __________Hours / Days / Weeks

Urgent Visit __________Hours / Days / Weeks

Contact Name

First Name

M.I.

Last Name

Title

Phone

Fax

–

–

–

–

Ext.

Tax I.D. Information I – Address I

•Information listed below will assist MultiPlan clients to pay your claims properly.

•All information must correspond to the W-9 Form submitted to the IRS.

Tax Identification Number									Tax ID Name______________________________________________________________________
									Tax ID Address ____________________________________________________________________
									(Note: This name must match the name associated with the Tax ID number on your W-9 Form.)

Address Information II

•Please provide practice, billing and mailing information for each office in which you see patients under this contract.

•Attach additional sheets if necessary.

■ Payment Address

■ Practice Address

■ Mailing Address

Street

Suite

City

State

Zip

-

Appointments

–

Fax

–

Ext.

Billing

–

–

Ext.

–

–

ATTESTATION / RELEASE TAX INFORMATION

After hours call coverage __________________________________________________________________________________________________________________

Average Appointment Scheduling Time

New patient __________Hours / Days / Weeks

Routine Visit __________Hours / Days / Weeks

Urgent Visit __________Hours / Days / Weeks

Contact Name

First Name

M.I.

Last Name

Title

Phone

Fax

–

–

–

–

Ext.

Tax I.D. Information II – Address II

•Information listed below will assist MultiPlan clients to pay your claims properly.

•All information must correspond to the W-9 Form submitted to the IRS.

Tax Identification Number									Tax ID Name______________________________________________________________________
									Tax ID Address ____________________________________________________________________
									(Note: This name must match the name associated with the Tax ID number on your W-9 Form.)

I hereby submit this application for participation with MultiPlan, Inc. through the PHCS Network and The MultiPlan Network. I understand that this application will be reviewed based on the information I have provided herein.

I hereby certify that the information contained and enclosed with this form is complete, accurate and true, and that information found to be false could result in denial or subsequent termination of my participation in the PHCS Network and The MultiPlan Network.

A photocopy of this permission will be as valid as the original.

X ________________________________________________________	_________________________________________________	____________________
Signature of Provider	Name (please type or print)	Date (mm,dd,yy)

MULTIPLAN USE ONLY REMEMBER TO ENCLOSE

1.■ Completed and signed Arkansas Preferred Physician Application.

2.■ One (1) completed and signed copy of the MultiPlan Participating Professional Agreement (with all Exhibits stapled to each Agreement).

3. ■ Copy of W-9 Form.

4.■ Copy of Curriculum Vitae. (optional)

Donʼt Forget To

■ Sign and date the Application

■ Keep a photocopy of the Application for your records.

PPO	Fee Schedule ______________________________________	Agreement ID ______________________________________________
OA	Fee Schedule ______________________________________	Agreement ID ______________________________________________