Wellmark Form S 2323 – Fill Out and Use This PDF

The Wellmark S 2323 form is a critical document designed for healthcare practitioners who are seeking to join Wellmark networks. It serves as an addendum to the Iowa Statewide Universal Practitioner Application, outlining specific criteria and requirements tailored to various specialties. As part of the application process, providers are expected to detail their hospital admitting privileges, prescribe medication electronically, amongst other qualifications, ensuring they meet Wellmark's standards for patient care. For healthcare professionals looking to expand their accessibility through Wellmark's network, completing the S 2323 form is a key step.

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Wellmark Form S 2323 PDF Details

The Wellmark S 2323 form stands as a pivotal addendum to the Iowa Statewide Universal Practitioner Application, tailored specifically for those seeking participation within Wellmark networks. This document meticulously outlines the prerequisites for healthcare professionals, including M.D.s, D.O.s, D.P.M.s, P.A.s, and A.R.N.P.s, delving into areas such as hospital admitting privileges, obstetrical services, and controlled substance prescribing levels. Furthermore, it navigates through the intricacies of credentialing at varied practice sites, mandating comprehensive disclosure about electronic medical records, prescribing practices, health status, and malpractice coverage. The form extends beyond the individual practitioner, requesting details on clinic affiliations, ownership interests, and practice focus, thereby embracing a holistic approach to provider information. In essence, the S 2323 form embodies a rigorous process designed to ensure that only qualified and competent practitioners are integrated into the Wellmark networks, safeguarding the provision of high-quality healthcare services. Moreover, it underscores Wellmark's discretion in application acceptance and stipulates conditions for the provision of information regarding practitioner network participation status, alongside invoking applicants’ rights to review and rectify their credentialing information. This comprehensive approach not only fortifies the credentialing process but also advocates for transparency and accountability within the healthcare provider network.

Question	Answer
Form Name	Wellmark Form S 2323
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	Obstetrical, hospitalist, S-2323, CDS

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WELLMARK, INC.

Iowa Universal Practitioner Application Addendum

To apply for participation in Wellmark networks, please complete this Addendum in addition to the Iowa Statewide Universal Practitioner Application. In it’s sole discretion, Wellmark reserves the right not to process or accept a provider’s application.

You are only required to answer the questions that apply to your specialty.

M.D./D.O., D.P.M., P.A., A.R.N.P.

Hospital Admitting Privileges

excluding allergy, anesthesiology, dermatology, emergency room, genetics, occupational medicine, pathology, psychiatry and radiology

c I attest that I have hospital admitting privileges at the hospitals identiied in Section E.

c I do not have hospital privileges but have the following arrangement for my patients to be admitted:

c Arrangement for hospital admissions by referral to a Wellmark participating physician or physician group.

_________________________________________	________________________________________
Name of physician or physician group	City/State

c Arrangement for hospital admissions by a Wellmark participating hospitalist or hospitalist group.

_________________________________________	________________________________________
Name of physician or physician group	City/State

Obstetrical Services (Family Practice, General Practice, Ob-Gyn, P.A., A.R.N.P. practicing in family or general practice or Ob-Gyn)

If a Family or General Practitioner, do you perform Obstetrical services? c Yes

c No

If a Family or General Practitioner performing Obstetrical services, do you perform deliveries? c Yes c No If an Obstetrics/Gynecology Practitioner, do you perform obstetrical services? c Yes c No

M.D./D.O., P.A., and A.R.N.P. and D.P.M.

State or Federal Controlled Substance

Level of drugs you can prescribe: c 2 c 3 c 4 c 5 c 2N c 3N

List the FDEA or CSA for the state in which you are applying for, if you do not have a current FDEA or CDS, please provide the name(s) of the practitioner(s) who will prescribe for your patients

Name	Title	NPI	Address	FDEA/CDS

Psychologists, Ph.D., Ed.D., Psy.D.

Licensing Information

Are you listed in the National Registry of Health Service Providers in Psychology? c Yes

c No

If yes, please indicate Registrant Number ________________________________________________________________

Original Issue Date ______/______/______

Mo Day Yr

Iowa HSP (Health Service Provider) Number ______________________________________________________________

Date Issued ______/______/______			Exp. Date ______/______/______
Mo	Day	Yr	Mo	Day	Yr

S-2323 5/13

Page 1

Site Speciic Information - If the information is different by practice site, please make a copy of this section and complete by practice site

The following information is for this practice site (address) _____________________________________________________

Group NPI _________________________________________________________________________________________

Credentialing Person’s Title _____________________________________________________________________________

Credentialing Fax Number ________________________ TDD Phone Number (for hearing impaired) ____________________

Do you store electronic medical records?

Do you prescribe medication electronically?

c Yes	c No
c Yes	c No

Health Status

During the last three years, have you ever been under the inluence of alcohol or illegal drugs during working hours, or have you

had a chemical dependency and/or substance abuse problem, treated or untreated? c Yes

c No

If yes, please explain: __________________________________________________________________________________

__________________________________________________________________________________________________

Are you unable, with or without reasonable accommodation, to practice to the fullest extent of your license, qualiications , and/or

privileges without in any way posing a risk of harm to your patients?	c Yes	c No
Have you ever been required to register as a sex ofender anywhere?	c Yes	c No

Malpractice

Next Policy Period: ___________________________________________________________________________________

Carrier Name _______________________________________________________________________________________

Policy Number ______________________	Aggregate Amount ________________ Per Claim Amount _________________
Efective Date _______/_______/_______	End Date _______/_______/_______

Directory Information

List this site and specialty in directory? c Yes

c No

Reason not listed c No patient appointments made at this site

cHospitalist

cCovering/Back up only

c Other ____________________________________________________________________________

Back-Up Physician Information (Blue Access®, hawk-i Blue Access, Blue Choice®, Blue Advantage®)

M.D.s/D.O.s, O.B./G.Y.N.s and P.A.s/A.R.N.P.s practicing as PCPs/O.B./G.Y.N.s: If you are applying for the managed care networks, you must designate a back-up.

Please list each individual providing back-up coverage for you, including their name, complete address, specialty, and NPI. Indicate this information for each site identiied in the Iowa Statewide Universal Practitioner Application. (If you need more space, use the last page of this addendum.)

Name	Address	Specialty	NPI	Efective
					Date

				/	/

				/	/

				/	/

				/	/

				/	/

				/	/

				/	/

				/	/

				/	/

				/	/

S-2323 5/13

Page 2

Site Speciic Information (cont) - If the information is different by practice site, please make a copy of this section and complete by practice site

Restrictions - mark the groups you want to see

Age? c No age restrictions c 0-5	c 6-12 c 13-17 c 18-65	c 65+
Gender? c No gender restrictions	c Female only c Male only _____________________________________________
Imaging Services Performed at your site
c CT	c MRI	c PET
c CTA	c Mammography	c PET/CT
c Echocardiography	c Nuclear Cardiology	c X-Ray
c MRA

Clinic Authorization and Agreement

For clinics with two or more providers - Please sign the following authorization for payment if you are billing as a clinic and want payment to come to you in the name of the clinic.

I authorize Wellmark Blue Cross and Blue Shield of Iowa to make payment to :

Clinic Name ______________________________________________________________________________________

Clinic Address_____________________________________________________________________________________

________________________________________________________________________________________________

for services that I perform. I agree that charges for my services will be uniform with all other physicians or health care providers that practice in the clinic named above.

Practitioner’s Signature ______________________________________________________ Date ______/______/______

Hospital-Based Practitioners

If you practice exclusively in a hospital setting, you are considered hospital-based. However, if you practice at other sites(s) outside the hospital and would like your name to appear in Wellmark’s provider directory, you will need to be credentialed.

Do you see patients outside of the hospital? c Yes

c No

Do you want to be listed at the other site(s) identiied in the Iowa Statewide Practitioner Universal Application, in the Wellmark

provider directory? c Yes

cNo

Ownership - If you have multiple ailiations please copy page and complete for each ailiation.

Document current ailiations with other health care or health related organizations.

Organization Name _________________________________________________________________________________

Address ________________________________________ City __________________ State ______ Zip _____________

Start Date ______/______/______ End Date ______/______/______

Position Held ___________________________________________________ Compensated c Yes

cNo

Do you own or a family member own or have ownership interest in a healthcare facility or organization that provides health or medical services (lab, nursing home, pharmacy, radiology/imaging center, rehab, HMO, medical equipment supplier, etc.)?

c Yes

cNo

If yes, then provide the following:

Name of Facility ___________________________________________________________________________________

Address _________________________________________________________________________________________

Percent of Ownership _______________ Owned By _______________________________________________________

Name of Organization _______________________________________________________________________________

S-2323 5/13

Page 3

All Practitioners (cont.)

Med/Surg & Behavioral Health Practice Focus

Please check those capabilities in which you focus your practice. These may or may not be a covered beneit. The information provided may be used to direct members to providers that practice in the areas indicated below.

Medical/Surgical

MD/DO’s Only	Medical Services:		Orthopedics:		Ophthalmology:
Surgery:	c Epilepsy		c Back Surgery		c Cataract Laser Surgery
	c Epilepsy		c Back Surgery		c Cataract Laser Surgery
c Bariatric			c Hip Surgery		c Cornea Specialist
c Gastric			c Joint Replacement		c Glaucoma Specialist
c Mastectomy			c Knee Surgery		c Oculoplastics
c Gynecological Oncology			c Shoulder Surgery		c Orbit Specialist
			c Wrist		c Retinal Specialist
Dental Surgery:					c Strabismus Specialist
Dental Surgery:
c TMJ Surgery
Dermatology:
c MOHS Surgery

Behavioral Health Practitioners Only

c ADD/ADHD		c Critical Incident Debrieing		c Home Care/Home Visits
c Addictions		c Depressive Disorder		c Hypnosis
c Adjustment Disorder		c Developmental Disabilities		c Infertility
c Adoption Issues		c Dialectical Behavior Therapy		c Learning Disabilities
c Anger Management		c Disability Evaluation		c Medical Stress/Behavioral Med
c Anxiety Disorder		c Dissociative Disorder		c Medication Management
c Asperger’s Syndrome		c Divorce		c Men’s Issues
c Autism Spectrum Disorders		c Domestic Violence		c Mood Disorders
c Bariatric Assessment		c Dual Diagnosis		c Multicultural Issues
c Behavior Modiication		c Eating Disorders		c Neuropsych Assessment
c Bi-Polar Disorder		c Faith-based Counseling		c Nursing Home Services
c Biofeedback		c Family Therapy		c Obesity Assessment & Counseling
c Child Abuse		c Forensic/Sex Ofenders		c Organic Brain Syndrome
c Christian Counseling		c Gay/Lesbian		c Pain Management
c Chronic Mental Illness		c Geriatric Mental Health		c Palliative Care
c Chronic Physical Illness		c Grief Counseling		c Panic Disorder
c Co-Dependency		c Gender Identity		c Parenting Skills
c Cognitive Behavioral Therapy		c Group Therapy		c Pastoral Counseling
c Compulsive Gambling		c Head Injury Patients		c Pervasive Development Disorders
c Conduct/Disruptive Disorders		c Hearing Impaired Issues		c Personality Disorder
c Couples/Marriage Therapy		c HIV Positive/AIDS Patients		c Phobias
c Crisis Intervention Services		c Home Based Services		c Physical Abuse/Violence

S-2323 5/13

Page 4

All Practitioners (cont.)

Behavioral Health Practitioners Only (cont.)

c Physically Impaired Patients	c Psychotic Disorders	c Somatoform Disorders
c Play Therapy	c Rape Victims	c Substance Abuse
c Police Personnel	c Schizophrenic Disorders	c Terminally Ill Patients
c Post Partum Issues	c Sex Ofender	c Visually Impaired Patients
c Post Traumatic Stress Disorder	c Sexual Abuse/Violence	c Women’s Issues
c Psych. Disability Eval/Mgmt	c Sexual Dysfunction	c Wound Care
c Psychological Testing	c Sexual Harassment
c Psychosomatic	c Sleep Disorders

Conﬁrmation of Practitioner Enrollment (Print Legibly)

For an electronic summary of the practitioner’s network participation status resulting from this application, complete the following ields. If you would like others to receive this information, such as billing staf, include e-mail addresses on the lines provided.

Primary Contact ___________________________________________________________________________________

Primary Contact Phone Number _______________________________________________________________________

Primary Contact E-mail Address _______________________________________________________________________

Other E-mail Address(es) ____________________________________________________________________________

________________________________________________________________________________________________

Note: If a contract is being signed as part of this application process, this option is not available. Contract(s) and participation status will be sent by mail.

Certiﬁcation and Release

Applicants have the following rights:

•You may request to review the information submitted in support of your credentialing application

•You may correct any erroneous information found in your credentialing iles

•You will be notiied if any information collected during the credentialing process varies substantially from the information you submitted

You must sign and date this section for all Wellmark networks. Please do not back date it. It will be returned if signature date is older than 60 days.

S-2323 5/13

Page 5

All Practitioners (cont.)

WELLMARK CERTIFICATION AND RELEASE

I understand that any information entered on this application and any Wellmark, Inc. addenda appropriate to my specialty identiied on pages 1 and 3 of the last Statewide Universal Practioners Application, which subsequently is found to be false could result in immediate dismissal from any Wellmark Blue Cross and Blue Shield of Iowa program.

I hereby certify that the information contained in this application is accurate, true and complete. I authorize release of information as may be required by Wellmark Blue Cross and Blue Shield of Iowa to process this application and understand and agree Wellmark Blue Cross and Blue Shield of Iowa may communicate with me through various means, including but not limited to telephone, mail, and/or e-mail over the internet, regarding my application.

My signature on this application does not constitute a contract with Wellmark Blue Cross and Blue Shield of Iowa. By signing this application, I authorize Wellmark Blue Cross and Blues Shield of Iowa to release this information to Wellmark subsidiaries and ailiates.

Practitioner’s Signature ______________________________________________________ Date ______/______/______

Practitioner’s Name (Please type or print) ________________________________________________________________

Complete this section if this application has been prepared by someone other than the applicant.

I, _________________________________, hereby attest that the information included on this application is correct and

complete and can be retrieved from the iles located at:

Clinic Name ______________________________________________________________________________________

Clinic Address_____________________________________________________________________________________

________________________________________________________________________________________________

Preparer’s Signature ________________________________________________________ Date ______/______/______

Instructions: Once you have completed the application, go to www.wellmark.com (Provider>Credentialing & Enrollment>Apply for

Participation>Step 3: Obtaining Your Participation Agreements) to access contracts. Please send the completed contract(s) with this application to the address given on the application instruction sheet.

S-2323 5/13

Page 6

Additional Information

__________________________________________________________________________________________________

S-2323 5/13

Page 7

How to Edit Wellmark Form S 2323 Online for Free

Using the online PDF editor by FormsPal, you can easily complete or modify hospitalist here. To make our editor better and more convenient to use, we constantly design new features, with our users' suggestions in mind. To get the ball rolling, consider these easy steps:

Step 1: Simply click the "Get Form Button" above on this page to start up our form editing tool. Here you'll find all that is needed to work with your document.

Step 2: With this handy PDF editing tool, it is possible to do more than merely complete blank fields. Express yourself and make your docs look faultless with customized textual content put in, or modify the original input to perfection - all supported by the capability to incorporate stunning photos and sign the document off.

This document will require specific information to be filled in, so you must take some time to fill in exactly what is required:

1. It is recommended to complete the hospitalist accurately, therefore take care while working with the parts containing these particular blanks:

2. The next stage is usually to complete the next few blank fields: State or Federal Controlled, Level of drugs you can prescribe c, List the FDEA or CSA for the state, names of the practitioners who, Name, Title, NPI, Address, FDEACDS, Psychologists PhD EdD PsyD, Licensing Information, Are you listed in the National, If yes please indicate Registrant, Original Issue Date Mo Day Yr, and Iowa HSP Health Service Provider.

It's simple to get it wrong when completing your Are you listed in the National, for that reason be sure to go through it again prior to when you submit it.

3. In this step, have a look at Site Speciic Information If the, practice site, The following information is for, Group NPI, Credentialing Persons Title, Credentialing Fax Number TDD, Do you store electronic medical, Do you prescribe medication, Health Status, During the last three years have, If yes please explain, Are you unable with or without, Have you ever been required to, Malpractice, and Next Policy Period. These are required to be completed with highest awareness of detail.

Iowa conclusion process clarified (stage 3)

4. To go onward, the next part requires typing in several form blanks. These comprise of Carrier Name, Policy Number Aggregate Amount, Efective Date End Date, Directory Information, List this site and specialty in, Reason not listed c No patient, c Other, BackUp Physician Information Blue, MDsDOs OBGYNs and PAsARNPs, Please list each individual, Name, Address, Specialty, NPI, and Efective, which you'll find vital to moving forward with this particular PDF.

5. The form should be wrapped up with this particular area. Further you'll see a full listing of blank fields that need accurate information in order for your document usage to be faultless: Page.

Iowa completion process detailed (part 5)

Step 3: Before moving forward, double-check that blanks were filled in correctly. Once you think it's all fine, click “Done." Download the hospitalist once you join for a free trial. Readily use the pdf within your FormsPal cabinet, with any edits and adjustments conveniently kept! We do not share any details you type in whenever completing forms at our site.

Wellmark Form S 2323 – Fill Out and Use This PDF

Wellmark Form S 2323 PDF Details

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