Nj Universal Physician Application Form PDF Details

The New Jersey Universal Physician Application represents a critical tool in the organized collection of personal, educational, and professional details of physicians practicing or intending to practice within the state. Devised with meticulous detail, this form encompasses a variety of sections, each oriented towards capturing specific data points crucial for a comprehensive understanding of a physician's qualifications and practice details. From basic personal information to more intricate details such as licensure, board certifications, medical education history, and professional liability insurance coverage, the form serves as a gateway for physicians to present their credentials systematically. It also addresses practical aspects of a physician's practice, including practice locations, types of services provided, hospital affiliations, privileges, and even details about previous work history. Furthermore, it prompts physicians to disclose other potentially relevant information such as interests in outside clinical labs, providing a layer of transparency important for regulatory and credentialing purposes. What makes this application particularly significant is its universality; designed to streamline the process by which physicians report their credentials across various platforms, thereby reducing redundancy and simplifying the verification process. This comprehensive approach not only enhances the efficiency of credentialing processes but also aids in maintaining a high standard of healthcare provision within New Jersey.

QuestionAnswer
Form NameNj Universal Physician Application Form
Form Length14 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 30 sec
Other namesuniversal physician application, form credentialing jersey, E-mail, Credentialing

Form Preview Example

New Jersey Universal Physician Application

(Please type or print)

SECTION 1

Personal Information

Physician Name (Last)

 

(First)

(MI) (Jr., Sr., etc.)

Professional Degree(s) (MD, DO,

Social Security Number

 

 

 

 

DDS, DMD, DPM, DC)

 

 

 

 

 

 

 

 

 

 

Other Name Used

 

 

Years Associated with

Other Name Used

 

Years Associated with

 

 

 

Former Name

 

 

 

Former Name

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

Gender

 

Are you eligible to work in the United States?

/

/

 

Male

Female

 

Yes

No

 

 

 

 

 

 

 

 

Home Mailing Address

 

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

Practice Location Information

Type of Service Provided

 

 

 

 

 

 

 

Primary Care Specialist

Non-Primary Care Specialist

 

 

 

 

 

 

 

 

Physician Group Name/Practice Name (to appear in the directory)

Group/Corporate Name (as it appears on W-9), if different from Group

 

 

 

 

 

Name/Practice Name

 

 

 

 

 

 

 

 

 

 

 

Primary Office Mailing Address

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

 

Primary Office Telephone No.

 

Primary Office Fax No.

 

Primary Office E-mail Address

 

 

 

 

 

 

Tax ID Number and Associated Individual Group Number and Name for This Location

 

 

 

 

 

 

 

 

Are you currently practicing at the above location?

 

 

If No, what is your expected start date?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Office Street Address

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

 

 

Telephone No.

 

 

Fax No.

 

E-mail Address

 

 

 

 

 

 

Do you want this site listed in the Directory?

 

Tax ID Number and Associated Individual Group Number and Name for This Location

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Office Street Address

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

 

Telephone No.

 

 

Fax No.

 

E-mail Address

 

 

 

 

 

 

Do you want this site listed in the Directory?

 

Tax ID Number and Associated Individual Group Number and Name for This Location

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Correspondence Office Street Address

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

 

Telephone No.

 

 

Fax No.

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

If you have additional offices, please submit an attachment containing the above information and check this box:

MC-5

 

DEC 05

Page 1 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

License and Other Identification Numbers

(License Information - Include all license(s) and certifications in all States where you are currently or have previously been licensed.)

 

Type

State(s) of

 

Do You Currently

License/Certificate

 

Expiration

 

N/A

 

Registration

 

Practice In This State?

Number

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEA Registration Certificate

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CDS Registration Certificate

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (CDS/DEA) (Specify)

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UPIN

 

National Provider ID

 

Are you a participating

Medicare Provider No.

Are you a participating

Medicaid Provider No.

 

 

(when available)

 

Medicare Provider?

 

 

Medicaid Provider?

 

 

 

 

 

 

 

 

 

 

 

International Medical Graduates: Are you certified by the Educational

If yes, ECFMG Number

 

ECFMG Issue Date

 

Council for Foreign Medical Graduates (ECFMG)?

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Education

School Issuing Professional Degree (Medical, Dental, Chiropractic)

Degree

Attendance Dates

Address

City

State/Country

Zip Code

If you have attended additional schools, please submit an attachment containing the above information and check this box:

Post-Graduate Education

 

Institution Name

 

 

Internship

Fellowship

 

 

 

Residency

Teaching Appointment

 

 

 

 

 

 

 

 

Address

 

City

State

Zip Code

 

 

 

 

 

Specialty

 

Start Date (Month/Year)

End Date (Month/Year)

 

 

 

 

 

Post-Graduate Education

 

Institution Name

 

 

Internship

Fellowship

 

 

 

Residency

Teaching Appointment

 

 

 

 

 

 

 

 

Address

 

City

State

Zip Code

 

 

 

 

 

Specialty

 

Start Date (Month/Year)

End Date (Month/Year)

 

 

 

 

 

Post-Graduate Education

 

Institution Name

 

 

Internship

Fellowship

 

 

 

Residency

Teaching Appointment

 

 

 

 

 

 

 

 

Address

 

City

State

Zip Code

 

 

 

 

 

Specialty

 

Start Date (Month/Year)

End Date (Month/Year)

 

 

 

 

 

If you completed additional training, please submit an attachment containing the above information and check this box:

Other Graduate Level Education for Which a Degree Was Obtained -

Institution Name

 

 

 

Type of Program (Psychology, Public Health, MBA, etc.)

 

 

 

 

 

 

 

 

 

Address

City

 

State

Zip Code

 

 

 

 

 

Degree Obtained

 

Date of Graduation (Month/Year)

 

 

 

 

 

MC-5

 

DEC 05

Page 2 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Professional/Medical Specialty Information

Primary Specialty

 

 

Board Certified?

 

Name of Certifying Board

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial Certification Date

 

 

Recertification Date (s) (if applicable)

 

Expiration Date (if applicable)

 

 

 

 

 

 

 

Do you wish to be listed in the directory under this specialty?

If not Board Certified, indicate any of the following that apply:

 

HMO

Yes

No

 

I have taken exam, results pending for:

 

(board)

PPO

Yes

No

 

I am intending to sit for the Boards on:

 

(date)

POS

Yes

No

 

I am not planning to take the Boards.

 

 

 

 

 

 

 

 

 

Secondary Specialty

 

 

Board Certified?

 

Name of Certifying Board

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

Initial Certification Date

 

 

Recertification Date (s) (if applicable)

 

Expiration Date (if applicable)

 

 

 

 

 

 

Do you wish to be listed in the directory under this specialty?

If not Board Certified, indicate any of the following that apply:

 

HMO

Yes

No

 

I have taken exam, results pending for:

 

(board)

PPO

Yes

No

 

I am intending to sit for the Boards on:

 

(date)

POS

Yes

No

 

I am not planning to take the Boards.

 

 

 

 

 

 

 

 

 

Additional Specialty

 

 

Board Certified?

 

Name of Certifying Board

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

Initial Certification Date

 

 

Recertification Date (s) (if applicable)

 

Expiration Date (if applicable)

 

 

 

 

 

 

Do you wish to be listed in the directory under this specialty?

If not Board Certified, indicate any of the following that apply:

 

HMO

Yes

No

 

I have taken exam, results pending for:

 

(board)

PPO

Yes

No

 

I am intending to sit for the Boards on:

 

(date)

POS

Yes

No

 

I am not planning to take the Boards.

 

 

 

 

 

 

 

 

 

 

 

List Additional Areas of Professional Practice, Interest or Focus (HIV/AIDS, etc.)

Hospital Affiliations and Privileges

Do you have hospital privileges?

 

If you do not admit patients, what admitting arrangements do you have?

 

Yes

No

 

 

 

 

If you have privileges, please complete the section below. Include all hospitals where you have privileges.

Primary Hospital where you have Admitting Privileges

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

Address

 

 

City

 

 

 

State

Zip Code

 

 

 

 

 

 

 

Full Unrestricted Privileges

Type of Privileges

Are Privileges Temporary?

 

Of the total admissions to all hospitals in the

Yes

No

 

Yes

No

 

past year, what percentage is to this specific

 

 

 

 

 

 

 

 

 

 

 

hospital?

 

Other Hospital Where you Have Privileges

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

Address

 

 

City

 

 

 

State

Zip Code

 

 

 

 

 

 

 

Full Unrestricted Privileges

Type of Privileges

Are Privileges Temporary?

 

Of the total admissions to all hospitals in the

Yes

No

 

Yes

No

 

past year, what percentage is to this specific

 

 

 

 

 

 

 

 

 

 

 

hospital?

 

Other Hospital Where you Have Privileges

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

Address

 

 

City

 

 

 

State

Zip Code

 

 

 

 

 

 

 

Full Unrestricted Privileges

Type of Privileges

Are Privileges Temporary?

 

Of the total admissions to all hospitals in the

Yes

No

 

Yes

No

 

past year, what percentage is to this specific

 

 

 

 

 

 

 

 

 

 

 

hospital?

 

Additional Hospital Where you Have Privileges

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

Address

 

 

City

 

 

 

State

Zip Code

 

 

 

 

 

 

 

Full Unrestricted Privileges

Type of Privileges

Are Privileges Temporary?

 

Of the total admissions to all hospitals in the

Yes

No

 

Yes

No

 

past year, what percentage is to this specific

 

 

 

 

 

 

 

 

 

 

 

hospital?

 

If you have additional hospital affiliations, please submit an attachment containing the above information and check this box:

MC-5

 

DEC 05

Page 3 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

List all other hospitals where you have previously had privileges.

Hospital Name

Dates of Affiliation

Address

City

State

Zip Code

Hospital Name

Dates of Affiliation

Address

City

State

Zip Code

If you have other previous hospital affiliations, please submit an attachment containing the above information and check this box:

Work History

Include chronological work history since completion of training.

Practice/Employer Name

Start Date/End Date

Address

City

State

Zip Code

Practice/Employer Name

Start Date/End Date

Address

City

State

Zip Code

Practice/Employer Name

Start Date/End Date

Address

City

State

Zip Code

Practice/Employer Name

Start Date/End Date

Address

City

State

Zip Code

For additional work history, please submit an attachment containing the above information and check this box:

Please provide an explanation of any gaps greater than six months in each work history.

Date

Explanation

Date

Explanation

Are you currently on active military duty or on military reserve?

Yes

No

References

Please provide three professional references that are not partners in your own group practice and are not relatives.

Name

Street Address

City, State, Zip Code

MC-5

 

DEC 05

Page 4 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Professional Liability Insurance Coverage

Are you self-insured?

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Current Malpractice Insurance Carrier or Self-Insured Entity

 

Telephone Number

Effective Date

Expiration Date

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

City

 

 

State

Zip Code

 

 

 

 

 

 

 

 

Policy Number

Amount of Coverage per Occurrence

 

Amount of Coverage Aggregate

Type of Coverage

Length of Time with

 

 

 

 

 

 

 

Individual

Carrier

 

 

 

 

 

 

 

Shared

 

Name of Previous Malpractice Insurance Carrier or Self-Insured Entity

 

Telephone Number

Effective Date

Expiration Date

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

City

 

 

State

Zip Code

 

 

 

 

 

 

 

Policy Number

Amount of Coverage per Occurrence

 

Amount of Coverage Aggregate

Type of Coverage

Length of Time with

 

 

 

 

 

 

 

Individual

Carrier

 

 

 

 

 

 

 

Shared

 

Status/Role in Practice

Owner

Partner

Employee

Officer

Shareholder

Interests in Outside Clinical Lab(s)

If you own/co-own, or have interests in any other outside clinical lab, please fill in below:

Legal Billing Name

TIN (Attach copy of W-9)

Clinical Description

 

 

 

Please provide a summary pattern for this business:

 

 

Office Coverage

 

List names of colleague(s) providing regular coverage and his/her specialty(ies).

 

Name

 

Provider Specialty

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Partners

 

List full names of all partners in your practice (attach list for large group).

 

Name (Last, First, MI)

 

Name (Last, First, MI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MC-5

 

DEC 05

Page 5 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Other Practice Information (specify for each site)

 

 

 

 

 

 

 

 

Site 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Site 2

 

 

 

 

 

 

Office Address:

 

 

 

 

 

 

 

 

 

 

 

Office Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Practice:

 

 

 

 

 

 

 

 

 

 

 

Type of Practice:

 

 

 

 

 

 

 

 

 

 

 

Solo

 

 

Single Specialty Group

Multi-Specialty Group

 

Solo

 

 

Single Specialty Group

Multi-Specialty Group

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Manager or Business Office Staff Contact::

 

 

 

 

Office Manager or Business Office Staff Contact::

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone No.:

 

 

 

 

 

 

 

 

 

 

 

 

Telephone No.:

 

 

 

 

 

 

 

 

 

 

 

Fax No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Credentialing Contact (if different from above):

 

 

 

 

Credentialing Contact (if different from above):

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone No.:

 

 

 

 

 

 

 

 

 

 

 

 

Telephone No.:

 

 

 

 

 

 

 

 

 

 

 

Fax No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax No.:

 

 

 

 

 

 

 

 

 

 

 

 

E-mail:

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail:

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

 

Zip:

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Billing Information:

 

 

 

 

 

 

 

 

 

 

 

Billing Information:

 

 

 

 

 

 

 

 

 

 

 

Billing Rep. Name:

 

 

 

 

 

 

 

 

Billing Rep. Name:

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

 

Zip:

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

 

Zip:

 

 

 

 

 

Telephone No.:

 

 

 

 

 

 

 

 

 

 

 

 

Telephone No.:

 

 

 

 

 

 

 

 

 

 

 

Fax No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax No.:

 

 

 

 

 

 

 

 

 

 

 

 

E-mail:

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail:

 

 

 

 

 

 

 

 

 

 

 

 

Dept. Name if Hosp.-Based:

 

 

 

 

 

 

 

 

 

Dept. Name if Hosp.-Based:

 

 

 

 

 

 

 

 

Check should be payable to

 

 

 

 

 

 

 

 

Check should be payable to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have capability of electronic billing?

Yes

No

 

Do you have capability of electronic billing?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Business Hours (hours patients are seen):

 

 

 

 

Office Business Hours (hours patients are seen):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

Day

 

Office

 

Morning

 

Afternoon

Evening

Day

 

Office

 

Morning

 

Afternoon

Evening

 

 

 

Hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hours

 

 

 

 

 

 

 

 

 

 

 

MON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TUES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TUES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THUR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THUR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FRI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FRI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SAT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SAT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

After hours, back office phone number

 

 

 

 

 

 

After hours, back office phone number

 

 

 

 

 

for health plan business use only:

 

 

 

 

 

 

 

for health plan business use only:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you provide 24 hour/7 day a

 

 

 

 

 

 

 

Do you provide 24 hour/7 day a

 

 

 

 

 

 

week phone coverage for this site?

 

Yes

No

 

 

 

week phone coverage for this site?

 

Yes

No

 

 

 

If yes, indicate type:

 

 

 

 

 

 

 

 

If yes, indicate type:

 

 

 

 

 

 

 

Answering service

 

 

 

 

 

 

 

 

Answering service

 

 

 

 

 

 

 

Voice mail with instructions to call answering service

 

 

 

 

Voice mail with instructions to call answering service

 

 

 

Voice mail with other instructions

 

 

 

 

 

 

 

Voice mail with other instructions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Continue on next page.)

MC-5

 

DEC 05

Page 6 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Other Practice Information (specify for each site)

(Continued from previous page.)

 

 

 

 

Site 1, Continued

 

 

 

 

 

 

 

 

 

Site 2, Continued

 

 

 

 

 

Do you accept new patients into the practice?

Yes

No

Do you accept new patients into the practice?

Yes

No

-All new patients?

 

 

 

 

 

Yes

No

-All new patients?

 

 

 

 

 

Yes

No

-Existing patients with change of payor?

 

Yes

No

-Existing patients with change of payor?

 

Yes

No

-New patients from physician referral?

 

Yes

No

-New patients from physician referral?

 

Yes

No

-New Medicare patients?

 

 

Yes

No

-New Medicare patients?

 

 

Yes

No

-New Medicaid patients?

 

 

Yes

No

-New Medicaid patients?

 

 

Yes

No

If this information varies by health plan, provide explanation:

If this information varies by health plan, provide explanation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are there any practice limitations?

Yes

 

 

No

 

 

Are there any practice limitations?

Yes

 

No

 

 

If yes, indicate limitations below:

 

 

 

 

 

 

If yes, indicate limitations below:

 

 

 

 

 

 

Gender:

Male Only

Female Only

N/A

 

 

Gender:

Male Only

Female Only

N/A

 

 

Patient Age Limitation (List Ages):

 

 

 

N/A

 

 

Patient Age Limitation (List Ages):

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List Other Limitations:

 

 

 

 

 

 

List Other Limitations:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do mid-level practitioners such as nurse

 

 

 

 

 

Do mid-level practitioners such as nurse

 

 

 

 

 

practitioners, physician assistants, midwives,

 

 

 

 

 

practitioners, physician assistants, midwives,

 

 

 

 

 

social workers or other non-physician providers

 

 

 

 

social workers or other non-physician providers

 

 

 

 

care for patients in your practice?

 

 

 

Yes

No

care for patients in your practice?

 

 

 

Yes

No

If yes, provide the following information for each staff member:

If yes, indicate limitations below:

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

Professional Designation:

 

 

 

 

 

 

 

 

Professional Designation:

 

 

 

 

 

 

 

 

State License Number:

 

 

 

 

 

 

 

State License Number:

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

Professional Designation:

 

 

 

 

 

 

 

 

Professional Designation:

 

 

 

 

 

 

 

 

State License Number:

 

 

 

 

 

 

 

State License Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please attach a list of any additional mid-level practitioners.

 

Please attach a list of any additional mid-level practitioners.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-English Languages spoken:

 

 

 

 

 

 

Non-English Languages spoken:

 

 

 

 

 

 

 

by health care professional:

 

 

 

 

 

 

 

by health care professional:

 

 

 

 

 

 

 

by office personnel:

 

 

 

 

 

 

 

 

by office personnel:

 

 

 

 

 

 

 

Are interpreters available?

Yes

No

 

 

 

Are interpreters available?

Yes

No

 

 

 

If yes, specify languages:

 

 

 

 

 

 

If yes, specify languages:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this office meet ADA

 

 

 

 

 

 

Does this office meet ADA

 

 

 

 

 

 

accessibility standards?

Yes

 

 

No

 

 

accessibility standards?

Yes

 

 

No

 

 

 

 

 

 

Does this site provide handicapped accessibility for each of the

Does this site provide handicapped accessibility for each of the

following:

 

 

 

 

 

 

 

 

 

following:

 

 

 

 

 

 

 

 

 

 

Building

 

 

 

Yes

 

 

No

 

 

 

Building

 

 

 

Yes

 

No

 

 

 

Parking

 

 

 

Yes

 

 

No

 

 

 

Parking

 

 

 

Yes

 

No

 

 

 

Restroom

 

 

 

Yes

 

 

No

 

 

 

Restroom

 

 

 

Yes

 

No

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this site have other services for the disabled?

 

 

Does this site have other services for the disabled?

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

Yes

 

No

If yes, indicate type:

 

 

 

 

 

 

 

 

 

If yes, indicate type:

 

 

 

 

 

 

 

 

 

 

Text Telephony - TTY

 

 

Yes

No

 

Text Telephony - TTY

 

 

Yes

 

No

 

American Sign Language-ASL

 

 

Yes

No

 

American Sign Language-ASL

 

 

Yes

 

No

 

Mental/Physical Impairment Services

 

Yes

No

 

Mental/Physical Impairment Services

 

Yes

 

No

 

Other:

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Continue on next page.)

MC-5

 

DEC 05

Page 7 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Other Practice Information (specify for each site)

(Continued from previous page.)

 

 

 

 

Site 1, Continued

 

 

 

 

 

 

 

 

Site 2, Continued

 

 

 

 

 

Is this site accessible by public transportation?

 

 

 

 

 

Is this site accessible by public transportation?

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

Yes

No

 

 

 

 

Bus

Yes

No

 

 

 

 

Bus

Yes

No

 

 

 

 

Subway

Yes

No

 

 

 

 

Subway

Yes

No

 

 

 

 

Regional Train

Yes

No

 

 

 

 

Regional Train

Yes

No

 

 

 

 

Other:

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this site provide childcare services?

Yes

No

 

Does this site provide childcare services?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this office qualify

 

 

 

 

 

 

Does this office qualify

 

 

 

 

 

 

as a minority business enterprise?

 

Yes

No

 

as a minority business enterprise?

 

Yes

No

 

Do you or does someone in your office have the following

 

 

 

Do you or does someone in your office have the following

 

 

 

certifications? (Indicate for each office location.)

 

 

 

 

 

certifications? (Indicate for each office location.)

 

 

 

 

 

 

 

Yes

No Exp.Date

 

 

 

 

 

Yes

No Exp.Date

 

BLS (Basic Life Support)

 

 

 

 

 

 

BLS (Basic Life Support)

 

 

 

 

 

 

ACLS (Advanced Cardiac Life Support)

 

 

 

 

 

ACLS (Advanced Cardiac Life Support)

 

 

 

 

 

ALSO (Advanced Life Support in OB)

 

 

 

 

 

ALSO (Advanced Life Support in OB)

 

 

 

 

 

PALS (Pediatric Advanced Life Support)

 

 

 

 

 

PALS (Pediatric Advanced Life Support)

 

 

 

 

 

ATLS (Advanced Trauma Life Support)

 

 

 

 

 

ATLS (Advanced Trauma Life Support)

 

 

 

 

 

NALS (Neonatal Advanced Life Support)

 

 

 

 

 

NALS (Neonatal Advanced Life Support)

 

 

 

 

 

CPR (Cardio-Pulmonary Resuscitation)

 

 

 

 

 

CPR (Cardio-Pulmonary Resuscitation)

 

 

 

 

 

 

 

 

 

 

 

 

 

Does your site provide any of the following services on site?

 

Does your site provide any of the following services on site?

 

(Indicate for each office location.)

 

 

 

 

 

 

(Indicate for each office location.)

 

 

 

 

 

 

Laboratory Services

 

Yes

No

 

Laboratory Services

 

Yes

No

 

Certificate of Participation from CLIA or

 

 

 

 

 

Certificate of Participation from CLIA or

 

 

 

 

 

another accrediting/certifying program

 

 

 

 

 

another accrediting/certifying program

 

 

 

 

 

[AAFP, COLA, CAP, Medical Laboratory

 

 

 

 

 

[AAFP, COLA, CAP, Medical Laboratory

 

 

 

 

 

Evaluation (MLE)] Program

 

Yes

No

 

Evaluation (MLE)] Program

 

Yes

No

 

If yes, list program:

 

 

 

 

 

 

 

If yes, list program:

 

 

 

 

 

 

 

Radiology Services

 

Yes

No

 

Radiology Services

 

Yes

No

 

X-Ray Certification

 

Yes

No

 

X-Ray Certification

 

Yes

No

 

If yes, include type:

 

 

 

 

 

 

 

If yes, include type:

 

 

 

 

 

 

 

EKG’s

 

Yes

No

 

EKG’s

 

Yes

No

 

Care of Minor Lacerations

 

Yes

No

 

Care of Minor Lacerations

 

Yes

No

 

Pulmonary Function Testing

 

Yes

No

 

Pulmonary Function Testing

 

Yes

No

 

Allergy Injections

 

Yes

No

 

Allergy Injections

 

Yes

No

 

Allergy Skin Testing

 

Yes

No

 

Allergy Skin Testing

 

Yes

No

 

Office Gynecology (Routine Pelvic/Pap)

Yes

No

 

Office Gynecology (Routine Pelvic/Pap)

Yes

No

 

Drawing Blood

 

Yes

No

 

Drawing Blood

 

Yes

No

 

Age Appropriate Immunizations

 

Yes

No

 

Age Appropriate Immunizations

 

Yes

No

 

Flexible Sigmoidoscopy

 

Yes

No

 

Flexible Sigmoidoscopy

 

Yes

No

 

Tympanometry/Audiometry Screening

Yes

No

 

Tympanometry/Audiometry Screening

Yes

No

 

Asthma Treatment

 

Yes

No

 

Asthma Treatment

 

Yes

No

 

Osteopathic Manipulation

 

Yes

No

 

Osteopathic Manipulation

 

Yes

No

 

IV Hydration/Treatment

 

Yes

No

 

IV Hydration/Treatment

 

Yes

No

 

Cardiac Stress Tests

 

Yes

No

 

Cardiac Stress Tests

 

Yes

No

 

Physical Therapy

 

Yes

No

 

Physical Therapy

 

Yes

No

 

 

 

 

 

 

 

Additional Office Procedures Provided (incl. surgical procedures)

 

Additional Office Procedures Provided (incl. surgical procedures)

 

 

 

 

 

 

 

 

 

 

 

Is anesthesia administered in your office?

Yes

No

 

Is anesthesia administered in your office?

Yes

No

 

If Yes, what class or category of anesthesia do you use?

 

 

 

If Yes, what class or category of anesthesia do you use?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who administers it?

 

 

 

 

 

 

Who administers it?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For additional office sites, please submit an attachment containing the above information and check this box:

MC-5

 

DEC 05

Page 8 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Patient Scheduling

What is patient wait time for emergency care? .................................................

What is patient wait time for urgent care?.........................................................

What is patient wait time for symptomatic care?...............................................

What is patient wait time for scheduling routine visits? .....................................

What is patient wait time for scheduling routine care? ......................................

What is average wait time for patients between waiting room and examination?

What is average wait time in minutes for returning a patient’s call?..................

Required Attachments or Supplemental Information

Please attach hard copy or scanned documents of the following:

Copy(ies) of DEA registration certificate(s)

Copy of state Controlled Dangerous Substance (CDS) registration certificate(s)

Copy of current professional liability insurance policy face sheet, showing expiration dates, limits and provider’s name

Copy(ies) of W-9(s) for verification of each tax identification number used

Copy of workers compensation certificate of coverage, if applicable

SECTION 2 - DISCLOSURE QUESTIONS

Please answer each question and include an explanation for any question answered “Yes.”

Licensure

1.Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation or have you ever been subject to

a consent order, probation or any conditions or limitations by any state licensing board?...................

2.Have you ever received a reprimand or been fined by any state licensing board?..............................

Yes

Yes

No No

Hospital Privileges and Other Affiliations

3.Have your clinical privileges at any hospital or healthcare institution 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 records 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? ..........................................................................................................

4.Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?.............................................................................................................................

5.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)? .....................................................................

Yes

Yes

Yes

No

No

No

Education, Training and Board Certification

6.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? .....................................................

7.Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship,

or other clinical education program?....................................................................................................

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

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

Yes

Yes

Yes

Yes

No

No No

No

MC-5

 

DEC 05

Page 9 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

DEA or CDS Certification/Authorization

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

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

 

 

voluntarily relinquished?

Yes

No

Medicare, Medicaid or Other Governmental Program Participation

11.Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified, subject to a recovery action 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

12.Are you currently or have you ever been 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? ......................................

13.To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?.........................................

14.Have you ever received sanctions from or been the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)? ....................................................................................................

15.Has a patient, employee, or co-worker ever accused you of sexual harassment or other illegal misconduct that resulted in an investigation, sanction or other formal action? ..........................

16.Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation by

a hospital or healthcare facility of any military agency? .......................................................................

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

Professional Liability Insurance Information and Claims History

17.Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history? ........................................................

18.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? ........................

Yes

Yes

No

No

Malpractice Claims History

19.Have you ever had any malpractice actions (pending, settled, dropped, dismissed, arbitrated, mediated or litigated)? If yes, provide information for each case on the attached form located

at the end of the Disclosure questions (list all separately)...................................................................

For any malpractice actions, please complete addendum and check this box:

Yes

No

Criminal/Civil History

(Note: A criminal record will not necessarily be a bar to acceptance. Decisions will be made by each health plan or credentialing organization based upon all relevant circumstances, including the nature of the crime.)

20.Have you ever been arrested, charged or indicted for, convicted of, pled guilty to, or pled nolo contendere to any felony, crime or other offense in the last ten years or been found liable or responsible for or named as a defendant in any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional? ...............

21.Have you ever been arrested, charged or indicted for, convicted of, pled guilty to, or pled nolo contendere to any felony, crime or other offense in the last ten years or been found liable or responsible for or been named as a defendant in any civil offense that alleged fraud,

an act of violence, child abuse or a sexual offense or sexual misconduct?.........................................

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

Yes

Yes

Yes

No

No

No

MC-5

 

DEC 05

Page 10 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Ability to Perform Job

23.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. § 812.22 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.)........................................................................................................................

24.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? .................

25.Do you have any reason to believe that you would pose a risk to the safety or well being of

your patients? ......................................................................................................................................

26.Are you able to perform the essential functions of a practitioner in your area of practice with

or without reasonable accommodation? ..............................................................................................

Yes

Yes

Yes

Yes

No

No

No

No

Please provide information below for Malpractice Actions indicated for Disclosure Question #19.

Date of occurrence:

Date claim was filed:

Claim/case status:

Professional liability carrier involved:

Address:

Telephone Number:

Policy Number:

Amount of award or settlement and amount paid:

Method of resolution:

Dismissed

Settled (with prejudice)

Settled (without prejudice)

 

Judgment for defendant(s)

Judgment for plaintiff(s)

Mediation or arbitration

Description of allegations:

Were you primary defendant or co-defendant?

Number of other co-defendants:

Your involvement in case (attending, consulting, etc.):

Description of alleged injury to the patient:

To the best of your knowledge, is this case included in the National Practitioner Data Bank (NPDB)?

Yes

No

MC-5

 

DEC 05

Page 11 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Please provide information below for any Disclosure Questions in Section II answered “Yes.”

Question

No.

Explanation

Provider Initials:

 

Date:

MC-5

 

DEC 05

Page 12 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

SECTION 3 - AUTHORIZATION, ATTESTATION AND RELEASE

I understand and agree that, as part of the credentialing application process for participation and/or clinical privileges (hereinafter, referred to as “Participation”) at or with

(indicate managed care company(s) to which you are applying) (hereinafter, individually referred to as the “Entity”), and any of the Entity’s affiliated entities, I am required to provide sufficient and accurate information for a proper evaluation of my current licensure, relevant training and/or experience, clinical competence, health status, character, ethics, and any other criteria used by the Entity for determining initial and ongoing eligibility for Participation. Each Entity and its representatives, employees, and agent(s) acknowledge that the information obtained relating to the application process will be held confidential to the extent permitted by law.

I acknowledge that each Entity has its own criteria for acceptance, and I may be accepted or rejected by each independently. I further acknowledge and understand that my cooperation in obtaining information and my consent to the release of information do not guarantee that any Entity will grant me clinical privileges or contract with me as a provider of services. I understand that my application for Participation with the Entity is not an application for employment with the Entity and that acceptance of my application by the Entity will not result in my employment by the Entity.

Authorizations

Investigation Concerning Application for Participation: I hereby authorize the following individuals including, without limitation, the Entity, its representatives, employees, and/or designated agent(s); the Entity’s affiliated entities and their representatives, employees, and/or designated agents; and the Entity's designated professional credentials verification organization (collectively referred to as “Agents”), to investigate information, which includes both oral and written statements, records, and documents, concerning my application for Participation. I agree to allow the Entity and/or its Agent(s) to inspect all records and documents relating to such an investigation.

Third-Party Sources to Release Information Concerning Application for Participation: I authorize any third party, including, but not limited to, individuals, agencies, medical groups responsible for credentials verification, corporations, companies, employers, former employers, hospitals, health plans, health maintenance organizations, managed care organizations, law enforcement or licensing agencies, insurance companies, educational and other institutions, military services, medical credentialing and accreditation agencies, professional medical societies, the Federation of State Medical Boards, the National Practitioner Data Bank, and the Health Care Integrity and Protection Data Bank, to release to the Entity and/or its Agent(s), information, including otherwise privileged or confidential information, concerning my professional qualifications, credentials, clinical competence, quality assurance and utilization data, character, mental condition, physical condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing on my qualifications for Participation in, or with, the Entity. I authorize my current and past professional liability carrier(s) to release my history of claims that have been made and/or are currently pending against me. I specifically waive written notice from any entities and individuals who provide information based upon this Authorization, Attestation and Release.

Release and Exchange of Disciplinary Information: I hereby further authorize any third party at which I currently have Participation or had Participation and/or each third party’s agents to release “Disciplinary Information,” as defined below, to the Entity and/or its Agent(s). I hereby further authorize the Agent(s) to release Disciplinary Information about any disciplinary action taken against me to its participating Entities at which I have Participation, and as may be otherwise required by law. As used herein, “Disciplinary Information” means information concerning: (i) any action taken by such health care organizations, their administrators, or their medical or other committees to revoke, deny, suspend, restrict, or condition my Participation or impose a corrective action plan; (ii) any other disciplinary action involving me, including, but not limited to, discipline in the employment context; or (iii) my resignation prior to the conclusion of any disciplinary proceedings or prior to the commencement of formal charges, but after I have knowledge that such formal charges were being (or are being) contemplated and/or were (or are) in preparation.

Provider Initials:

 

Date:

MC-5

 

DEC 05

Page 13 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Releases

Release from Liability. I release from all liability and hold harmless any Entity, its Agent(s), and any other third party for their acts performed in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of the Entity, its Agent(s), or other third party in connection with the gathering, release and exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release. I further agree not to sue any Entity, any Agent(s), or any other third party for their acts, defamation or any other claims based on statements made in good faith and without malice or misconduct of such Entity, Agent(s) or third party in connection with the credentialing process. This release shall be in addition to, and in no way shall limit, any other applicable immunities provided by law for peer review and credentialing activities.

In this Authorization, Attestation and Release, all references to the Entity, its Agent(s), and/or other third party include their respective employees, directors, officers, advisors, counsel, and agents. The Entity or any of its affiliates or agents retains the right to allow access to the application information for purposes of a credentialing audit to customers and/or their auditors to the extent required in connection with an audit of the credentialing processes and provided that the customer and/or their auditor executes an appropriate confidentiality agreement. I understand and agree that this Authorization, Attestation and Release is irrevocable for any period during which I am an applicant for Participation at an Entity, a member of an Entity's medical or health care staff, or a participating provider of an Entity. I agree to execute another form of consent if law or regulation limits the application of this irrevocable authorization. I understand that my failure to promptly provide another consent may be grounds for termination or discipline by the Entity in accordance with the applicable bylaws, rules, and regulations, and requirements of the Entity, or grounds for my termination of Participation at or with the Entity. I agree that information obtained in accordance with the provisions of this Authorization, Attestation and Release is not and will not be a violation of my privacy.

Attestation

I certify that all information provided by me in my application is true, correct, and complete to the best of my knowledge and belief, and that I will notify the Entity and/or its Agent(s) within 10 days of any material changes to the information I have provided in my application or authorized to be released pursuant to the credentialing process. I understand that corrections to the application are permitted at any time prior to a determination of Participation by the Entity, and must be submitted on-line or in writing, and must be dated and signed by me (may be a written or an electronic signature). I understand and agree that the information provided on this application may be shared with appropriate State and federal agencies.

I understand and agree that any material misstatement or omission in the application may constitute grounds for withdrawal of the application from consideration; denial or revocation of Participation; and/or immediate suspension or termination of Participation. This action may be disclosed to the Entity and/or its Agent(s). I further understand and agree that submitting false, misleading or incomplete information may result in the imposition of administrative, civil and/or criminal sanctions, in accordance with State and federal law.

I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release. I understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.

Name (Print or Type)

Social Security Number

Signature

Date

MC-5

 

DEC 05

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