W Welc ome e to o Da avis Vis sion !

Transcription

Welc
W ome
e to
o Da
avis Vis
sion!
eady to start processing
g your application! Befo
ore we can begin, we’ll need 3 simple
We’re re
documen
nts submitted
d to us:
1. A signed cop
py of the las
st page of the
t
Davis
D
Vision
n Contract:
2. A completed
d Davis Vision Provider Add Form
m:
our W9 Form
m:
3. A copy of yo
y
completed docum
ments to 1.8
888.553.284
47 or call 1.8
800.584.314
40 for more
Fax your
info
ormation. CREDENTIALING DOCUMENT REQUIREMENTS
FOR NETWORK PARTICIPATION
STATE OF LOUISIANA
Complete all information and provide documents listed below.* No authorization to
provide services shall be granted prior to an applicant’s satisfactory completion of the
credentialing process.
A valid National Provider Identifier number is a required element of the application
process. Provide your Individual NPI number on the application. Provide your
Organizational NPI number either on the application or include documentation of your
Organizational NPI number from CMS on a separate sheet.
____________
APPLICATION
CAQH Provider Application
PARTICIPATING PROVIDER AGREEMENT^
^All applicants/practitioners must sign and complete all information required on
the signature page of the Participating Provider Agreement, and must return the
signed (complete), original Provider Agreement to Davis Vision.
COPY OF BLANK, PATIENT EXAM FORM
W-9 FORM
*Kindly forward all documentation to: Davis Vision, Inc., 159 Express Street, Plainview,
NY 11803-Attn: Recruiting Dept.
042211
Confidential\Credentialing\Checklist\Louisiana
Provider Application
CORRECT NUMBERS
AND LETTERS
A B C
Instructions
Read all instructions
carefully prior to
submitting your
application.
1 2 3
X
CORRECT
MARK
CAQH AUTOMATICALLY APPLIES MIXED-CASE FORMATTING,
COMMON ABBREVIATIONS, AND ZIP CODE MATCHING. PLEASE
MAKE CORRECTIONS ONLINE OR CALL THE HELP DESK.
•
INCORRECT
MARKS
Tips to avoid processing delays
1. Complete only this application and its supplemental forms. Do not use another provider’s application.
2. Use a blue or black ink ball-point pen only. Do not use a pencil or a felt-tip pen.
3. Print legibly and inside the boxes provided based upon the examples given above.
4. Do not enter more than 1 character per box. If necessary, write outside the provided spaces.
5. Complete all sections that are applicable to you.
6. Some fields use “codes” to help you easily report information (e.g., schools, languages). Code lists are found on pages 36 - 43.
NOTE: Fields with asterisks (*) indicate that a response is required. All other fields will be considered not applicable if left blank.
SECTION 1
Personal Information and Professional IDs
Code list is found on page 36. Enter the
associated 3-digit code in the space
provided.*
Provider Type
YES
DO YOU PRACTICE EXCLUSIVELY WITHIN THE INPATIENT SETTING?*
(E.G. PATHOLOGISTS, ANESTHESIOLOGISTS, ER PHYSICIANS, NURSE
PRACTITIONER, RADIOLOGISTS, PHYSICIAN ASSISTANT, ETC.)
NO
Name
Do not use nicknames
or initials, unless they
are part of your legal
name.
LAST NAME*
SUFFIX (JR, III)
FIRST NAME*
MIDDLE NAME
HAVE YOU EVER USED ANOTHER NAME?*
YES
NO
IF YES, PLEASE LIST ALL OTHER NAMES USED AND THEIR DATES OF USE BELOW.
OTHER LAST NAME
SUFFIX (JR, III)
OTHER FIRST NAME
M M
OTHER MIDDLE NAME
D D
Y
Y
Y
Y
DATE STARTED USING OTHER NAME
General
Information
Only enter a Foreign
National Identification
Number if you do not
have a SSN. Do not
enter National Provider
Identification (NPI)
Number here.
GENDER*
MALE
D D
Y
Y
Y
Y
DATE OF BIRTH*
FEMALE
M M
D D
Y
Y
Y
CITY OF BIRTH
Y
STATE OF
BIRTH
-
SSN*
Code lists are found on
pages 36-43. Enter the
associated 3-digit code
in the space provided.
M M
DATE STOPPED USING OTHER NAME
COUNTRY OF
BIRTH
FOREIGN NATIONAL IDENTIFICATION NUMBER (FNIN)
FNIN COUNTRY OF ISSUE
ENTER ALL NON-ENGLISH
LANGUAGES YOU SPEAK
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
Home Address
NUMBER
STREET
APT NUMBER
CITY
STATE
-
ZIP CODE
-
TELEPHONE
NOTE: CAQH will use
this method for
application follow-up.
E-MAIL
FAX
-
-
PREFERRED METHOD OF CONTACT*
E-MAIL
FAX
3076
* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
Page 01
Std. App. v.5.0
Reprinted on 10/31/06
Section 1
Personal Information and Professional IDs (Continued)
Professional
IDs
Include all state
licenses, DEA
Registration and State
Controlled Dangerous
Substance (CDS)
certification numbers.
Provide all current and
previous licenses/
certifications.
M M D D Y
FEDERAL DEA NUMBER
DEA ISSUE DATE
DEA STATE OF REGISTRATION
DEA EXPIRATION DATE
CDS CERTIFICATE NUMBER
CDS ISSUE DATE
M M D D Y
M M D D Y
M M D D Y
CDS STATE OF REGISTRATION
Non-licensed
professionals should
enter certification/
registration number in
the space provided for
license number.
If you have additional
Professional IDs to
report, use the
Professional IDs
Supplemental Form on
page 19.
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
CDS EXPIRATION DATE
M M D D Y
STATE LICENSE NUMBER
LICENSE ISSUING STATE
IF THIS IS A STATE LICENSE, ARE YOU
CURRENTLY PRACTICING IN THIS STATE?
YES
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
LICENSE ISSUE DATE
M M D D Y
NO
LICENSE EXPIRATION DATE
Code list is found on page 36;
use license status codes. Enter
3-digit code in space provided.
use provider type codes. Enter
LICENSE STATUS CODE
LICENSE TYPE
M M D D Y
YES
LICENSE ISSUE DATE
NO
M M D D Y
LICENSE STATUS CODE
Other ID
Numbers
ARE YOU A PARTICIPATING MEDICARE
PROVIDER?*
Professional IDs to
report, use the
Professional IDs
page 19.
ARE YOU A PARTICIPATING MEDICAID
PROVIDER?*
LICENSE TYPE
YES
NO
MEDICARE NUMBER
YES
UPIN
NO
MEDICAID NUMBER
NATIONAL PROVIDER IDENTIFICATION (NPI) NUMBER
MEDICAID STATE
USMLE NUMBER (WITHOUT HYPHENS)
WORKERS COMPENSATION NUMBER
0
—
—
—
M M D D Y
ECFMG NUMBER (NON-U.S./CANADIAN GRADUATE ONLY)
Y
Y
Y
ECFMG CERTIFICATE ISSUE DATE (NON-U.S./CANADIAN GRADUATE ONLY)
3077
Page 02
Std. App. v.5.0
Section 2
Education and Training
Undergraduate
School(s)
UNDERGRADUATE SCHOOL
Provide the appropriate
information for the
school that issued your
undergraduate degree
and all schools
attended.
OFFICIAL NAME OF UNDERGRADUATE SCHOOL
ADDRESS
CITY
STATE
Professional
School(s)
Provide the appropriate
information for the
school that issued your
professional degree.
Fifth Pathway Graduates
please complete the
following sections: U.S.
School that issued your
certificate, the Non-U.S.
School where you
attended, and the Fifth
Pathway institution
where you completed
your training on
Supplemental Page 20.
Undergraduate or
Professional Schools to
report, use the
Education Supplemental
Form on page 20.
COUNTRY CODE
M M Y
ZIP/POSTAL CODE
-
-
TELEPHONE
Y
Y
Y
M M Y
START DATE
Y
Y
Y
END DATE (GRADUATION DATE)
DID YOU COMPLETE YOUR
UNDERGRADUATE EDUCATION
AT THIS SCHOOL?
YES
-
FAX
DEGREE AWARDED
NO
GRADUATE TYPE*:
U.S. OR CANADIAN GRADUATE
NON-U.S./CANADIAN GRADUATE
FIFTH PATHWAY GRADUATE
U.S. OR CANADIAN SCHOOL
SCHOOL CODE (U.S./
CANADIAN ONLY)
M M Y
Y
NAME OF U.S./
CANADIAN SCHOOL:
Y
Y
M M Y
START DATE*
Y
Y
Y
END DATE (GRADUATION DATE)*
GRADUATE EDUCATION AT THIS
SCHOOL?
YES
DEGREE AWARDED
NO
NON - U.S. OR CANADIAN SCHOOL
OFFICIAL NAME OF NON-U.S. PROFESSIONAL SCHOOL
ADDRESS
CITY
M M Y
COUNTRY CODE
Y
Y
Y
M M Y
START DATE*
GRADUATE EDUCATION AT THIS
SCHOOL?
Y
Y
Y
END DATE (GRADUATION DATE)*
YES
POSTAL CODE
DEGREE AWARDED
NO
3078
Page 03
Std. App. v.5.0
Section 2
Education and Training (Continued)
Training
List all training
programs you
attended. Use one
section per institution.
post-graduate training
programs, use the
Supplemental Training
Form on page 21.
Please explain on the
Supplemental
Professional / Work
History Gap Form on
page 33 any training
gap(s) of three (3)
months or greater, or
any gap(s) of a shorter
duration if required by
the organization for
which you are being
credentialed.
SCHOOL CODE (E.G.,
AFFILIATED MEDICAL
SCHOOL)
INSTITUTION/HOSPITAL NAME (USE BOTH LINES IF REQUIRED)
NUMBER
STREET
SUITE/BUILDING
CITY
STATE
-
ZIP/POSTAL CODE
-
-
TELEPHONE
COUNTRY CODE
DID YOU COMPLETE THIS TRAINING PROGRAM AT THIS
INSTITUTION?
-
FAX
YES
NO
(IF NOT, PLEASE USE THE SPACE BELOW TO EXPLAIN.)
List each
department
separately, if
applicable.
List
Internship/
Residency,
Fellowship
and Other
programs
separately.
INTERNSHIP/
RESIDENCY
FELLOWSHIP
OTHER
M M Y
Y
Y
Y
START DATE
M M Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
END DATE
DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)
NAME OF DIRECTOR
INTERNSHIP/
RESIDENCY
FELLOWSHIP
OTHER
M M Y
Y
Y
Y
START DATE
M M Y
END DATE
NAME OF DIRECTOR
INTERNSHIP/
RESIDENCY
FELLOWSHIP
OTHER
M M Y
Y
Y
Y
START DATE
M M Y
END DATE
NAME OF DIRECTOR
3080
Page 04
Std. App. v.5.0
*
Section 3
Primary
Specialty
REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
Professional / Medical Specialty Information
SPECIALTY
CODE
BOARD
CERTIFIED?
YES
NO
CERTIFYING
BOARD
CODE
IF NOT
BOARD
CERTIFIED
(SELECT
ONE)
INITIAL
CERTIFICATION
DATE
M M D D Y
Y
Y
Y
RECERTIFICATION
DATE
(IF APPLICABLE)
M M D D Y
Y
Y
Y
EXPIRATION DATE
(IF APPLICABLE)
M M D D Y
Y
Y
Y
I HAVE TAKEN
EXAM, RESULTS
PENDING FOR
DO YOU WISH TO
BE LISTED IN
THE DIRECTORY
UNDER THIS
SPECIALTY?
I INTEND TO SIT FOR AN
EXAM ON
M M D D Y
HMO
YES
NO
PPO
YES
NO
POS
YES
NO
I DO NOT INTEND TO TAKE
A CERTIFYING BOARD EXAM.
Y
Y
Y
CERTIFYING BOARD CODE
IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE A CERTIFYING BOARD EXAM, PLEASE USE THE
FOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.
Secondary
Specialty
Professional / Medical
Specialties to report,
use the Additional
Specialties
page 22.
SPECIALTY
CODE
BOARD
CERTIFIED?
YES
NO
CERTIFYING
BOARD
CODE
IF NOT
BOARD
CERTIFIED
(SELECT
ONE)
I HAVE TAKEN
EXAM, RESULTS
PENDING FOR
INITIAL
CERTIFICATION
DATE
M M D D Y
Y
Y
Y
RECERTIFICATION
DATE
(IF APPLICABLE)
M M D D Y
Y
Y
Y
EXPIRATION DATE
(IF APPLICABLE)
M M D D Y
Y
Y
Y
EXAM ON
M M D D Y
DO YOU WISH TO
BE LISTED IN
THE DIRECTORY
UNDER THIS
SPECIALTY?
HMO
YES
NO
PPO
YES
NO
POS
YES
NO
Y
Y
Y
3081
Page 05
Std. App. v.5.0
Section 3
Certifications
Professional / Medical Specialty Information (Continued)
Do you hold the following certifications? If yes, provide expiration dates.
EXPIRATION DATE
EXPIRATION DATE
Y
ADV LIFE
SUPPORT IN
OB?*
YES
NO
M M D D Y
Y
Y
Y
Y
Y
ADV TRAUMA
LIFE
SUPPORT?*
YES
NO
M M D D Y
Y
Y
Y
Y
Y
Y
PEDIATRIC
ADVANCED
LIFE SPT?*
YES
NO
M M D D Y
Y
Y
Y
Y
Y
Y
BASIC LIFE
SUPPORT?*
YES
NO
M M D D Y
Y
Y
CPR?*
YES
NO
M M D D Y
Y
ADV
CARDIAC
LIFE SPT?*
YES
NO
M M D D Y
NEONATAL
ADVANCED
LIFE SPT?*
YES
NO
M M D D Y
Practice
Interests
Provide additional
areas of professional
practice interest,
activities, procedures,
diagnoses or
populations.
Primary
Credentialing
Contact
CHECK HERE TO
USE THE OFFICE
MANAGER AND
ADDRESS OF THE
PRIMARY PRACTICE
LOCATION AS THE
CREDENTIALING
INFORMATION.
LAST NAME
M.I.
FIRST NAME
NUMBER
STREET
SUITE/BUILDING
CITY
NOTE:
Even if you checked
the boxes above,
please provide the
e-mail address, if
available.
STATE
TELEPHONE
-
-
ZIP CODE
-
FAX
E-MAIL ADDRESS
3082
Page 06
Std. App. v.5.0
Section 4
Primary
Practice
Location
practice locations, use
the Supplemental
Practice Location
Information Form on
pages 25-29.
Practice Location Information
NOTE: IF YOU INDICATED THAT YOU PRACTICE EXCLUSIVELY WITHIN THE INPATIENT SETTING ON PAGE 1, YOU ARE ONLY REQUIRED TO COMPLETE THE
CREDENTIALING CONTACT QUESTION ABOVE. SECTION 4 MAY BE LEFT BLANK. YOU MAY PROCEED TO SECTION 5 ON PAGE 11.
CURRENTLY
PRACTICING AT
THIS ADDRESS?*
YES
NO
PREVIOUS
OR FUTURE
START DATE?
M M D D Y
Y
Y
Y
PHYSICIAN GROUP / PRACTICE NAME TO APPEAR IN DIRECTORY (DO NOT ABBREVIATE)*
GROUP / CORPORATE NAME AS IT APPEARS ON W-9, IF DIFFERENT FROM ABOVE (DO NOT ABBREVIATE)
NOTE: “General
Correspondence” refers
to any correspondence
that might be sent to the
provider that does not
solely relate to credentialing or billing
information.
TIP Your Individual Tax
ID is assumed to be
your Primary Tax ID
unless you specify
otherwise to the right.
NUMBER*
STREET*
CITY*
SEND GENERAL
CORRESPONDENCE HERE?*
YES
-
STATE*
ZIP CODE*
-
-
FAX
OFFICE E-MAIL ADDRESS
-
-
INDIVIDUAL TAX ID
List each contact
separately. You may
use the check boxes
below for convenience.
Do not write
instructions like “see
above”. These
responses will be
rejected and will
require follow-up.
-
NO
TELEPHONE*
Office Manager
or Business
Office Staff
Contact
SUITE/BUILDING
PRIMARY
TAX ID
(ONE ONLY)*
-
USE INDIVIDUAL
TAX ID
USE GROUP
TAX ID
GROUP TAX ID
LAST NAME*
FIRST NAME*
M.I.
-
-
TELEPHONE*
-
-
FAX
E-MAIL ADDRESS
Billing Contact
LAST NAME*
CHECK HERE TO
USE OFFICE
MANAGER AND
OFFICE ADDRESS
AS BILLING
INFORMATION
M.I.
FIRST NAME*
NUMBER*
STREET*
SUITE/BUILDING
NOTE:
STATE*
CITY*
Even if you checked
the box above, please
provide the
E-mail Address of the
Billing Contact.
TELEPHONE*
-
-
ZIP CODE*
-
FAX
E-MAIL ADDRESS
3083
Page 07
Std. App. v.5.0
Section 4
Payment and
Remittance
Practice Location Information (Continued)
ELECTRONIC
BILLING
CAPABILITIES?*
YES
NO
BILLING DEPARTMENT (IF HOSPITAL-BASED)
YOUR “CHECK PAYABLE TO”
INFORMATION SHOULD BE
CONSISTENT WITH YOUR
W-9.
CHECK HERE TO
USE OFFICE
MANAGER AND
OFFICE ADDRESS
AS PAYEE
INFORMATION
CHECK PAYABLE TO*
LAST NAME*
M.I.
FIRST NAME*
NUMBER*
STREET*
SUITE/BUILDING
NOTE:
Even if you checked
the box above, please
provide the
E-mail Address of the
Payee Contact.
CITY*
STATE*
-
-
-
TELEPHONE*
ZIP CODE*
-
FAX
E-MAIL ADDRESS
Office Hours
(USE HHMM FORMAT AND ROUND TO THE NEAREST HALF-HOUR)
A=AM
P=PM
START
A=AM
P=PM
END
START
MONDAY
FRIDAY
TUESDAY
SATURDAY
WEDNESDAY
SUNDAY
A=AM
P=PM
A=AM
P=PM
END
NOTE:
After hours back office
telephone will be used
only by the health plan
and will not be
published under any
circumstances.
Open Practice
Status
THURSDAY
24/7 PHONE COVERAGE?*
YES
NO
AFTER HOURS BACK OFFICE TELEPHONE
IF YES
VOICE MAIL WITH
INSTRUCTIONS TO CALL
ANSWERING SERVICE
ANSWERING
SERVICE
VOICE MAIL
WITH OTHER
INSTRUCTIONS
-
-
ACCEPT NEW PATIENTS INTO THIS PRACTICE?*
YES
NO
ACCEPT ALL NEW PATIENTS?*
YES
NO
ACCEPT EXISTING PATIENTS WITH CHANGE OF PAYOR?*
YES
NO
ACCEPT NEW MEDICARE PATIENTS?*
YES
NO
ACCEPT NEW PATIENTS WITH PHYSICIAN REFERRAL?*
YES
NO
ACCEPT NEW MEDICAID PATIENTS?*
YES
NO
IF ANY OF THE
ABOVE INFORMATION
VARIES BY PLAN,
EXPLAIN (USE BOTH
LINES IF REQUIRED)
ARE THERE ANY
PRACTICE LIMITATIONS?*
YES
NO
GENDER LIMITATIONS
IF YES
MALE
ONLY
AGE LIMITATIONS
NONE
LIST OTHER LIMITATIONS
MINIMUM
AGE
MAXIMUM
AGE
FEMALE
ONLY
3084
Page 08
Std. App. v.5.0
Section 4
Mid-Level
Practitioners
DO MID-LEVEL PRACTITIONERS (NURSE PRACTITIONERS, PHYSICIAN
ASSISTANTS, ETC.) CARE FOR PATIENTS IN YOUR PRACTICE?*
YES
NO
(IF YES, PLEASE PROVIDE THE INFORMATION BELOW)
PRACTITIONER LAST NAME
PRACTITIONER FIRST NAME
M.I.
PRACTITIONER TYPE (E.G., PA,
CNP, NP)
M.I.
CNP, NP)
M.I.
CNP, NP)
PRACTITIONER STATE
PRACTITIONER LICENSE / CERTIFICATE NUMBER
PRACTITIONER STATE
PRACTITIONER STATE
M.I.
CNP, NP)
PRACTITIONER STATE
M.I.
CNP, NP)
PRACTITIONER STATE
3085
Page 09
Std. App. v.5.0
Section 4
Languages
pages 37. Enter the
Accessibilities
LANGUAGES
NON-ENGLISH LANGUAGES
SPOKEN BY OFFICE PERSONNEL
LANGUAGE CODE
INTERPRETERS
AVAILABLE?*
YES
NO
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
DOES THIS OFFICE MEET ADA ACCESSIBILITY REQUIREMENTS?*
DOES THIS SITE OFFER HANDICAPPED
ACCESS FOR THE FOLLOWING
YES
NO
DOES THIS SITE OFFER OTHER
SERVICES FOR THE DISABLED?*
YES
NO
ACCESSIBLE BY
PUBLIC TRANSPORTATION?*
YES
NO
BUILDING?*
YES
NO
TEXT TELEPHONY (TTY)*
YES
NO
BUS*
YES
NO
PARKING?*
YES
NO
AMERICAN SIGN LANGUAGE*
YES
NO
SUBWAY*
YES
NO
RESTROOM?*
YES
NO
MENTAL/PHYSICAL IMPAIRMENT
SERVICES*
YES
NO
REGIONAL TRAIN*
YES
NO
OTHER HANDICAPPED ACCESS
Services
LANGUAGE CODE
LANGUAGES
INTERPRETED
OTHER TRANSPORTATION ACCESS
OTHER DISABILITY SERVICES
Does this location provide any of the following services?
LABORATORY
SERVICES?
YES
NO
IF YES, PROVIDE ACCREDITING/
CERTIFYING PROGRAM
(E.G., CLIA, COLA, MLE)
RADIOLOGY
SERVICES?
YES
NO
IF YES, PROVIDE X-RAY
CERTIFICATION TYPE
EKGS?
YES
NO
ALLERGY
INJECTIONS?
YES
NO
ALLERGY SKIN
TESTING?
YES
NO
ROUTINE OFFICE
GYNECOLOGY
(PELVIC/PAP)?
YES
NO
DRAWING
BLOOD?
YES
NO
AGE
APPROPRIATE
IMMUNIZATIONS?
YES
NO
FLEXIBLE
SIGMOIDOSCOPY?
YES
NO
TYMPANOMETR
Y/ AUDIOMETRY
SCREENING?
YES
NO
ASTHMA
TREATMENT?
YES
NO
OSTEOPATHIC
MANIPULATION?
YES
NO
IV HYDRATION/
TREATMENT?
YES
NO
CARDIAC
STRESS TEST?
YES
NO
YES
NO
PHYSICAL
THERAPY?
YES
NO
CARE OF MINOR
LACERATIONS?
YES
NO
YES
NO
IF YES, WHAT
CLASS/CATEGORY
DO YOU USE?
PULMONARY
FUNCTION
TESTING?
IS ANESTHESIA
ADMINISTERED IN
YOUR OFFICE?
IF YES, WHO
ADMINISTERS IT?
LAST NAME
TYPE OF PRACTICE
(SELECT ONE ONLY)*
FIRST NAME
SOLO PRACTICE
SINGLE SPECIALTY GROUP
MULTI-SPECIALTY GROUP
ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)
3086
Page 10
Std. App. v.5.0
Section 4
Partners/
Associates
LIST ALL PARTNERS/ASSOCIATES AT THIS PRACTICE
LAST NAME
SPECIALTY CODE
FIRST NAME
partners/associates at
THIS location, use the
Partner/Associate
page 23. Photocopy as
necessary. Be certain
to check “Primary
Location” at the top of
the page.
M.I.
LAST NAME
M.I.
FIRST NAME
M.I.
COVERING
COLLEAGUE
(Y/N)?
PROVIDER TYPE (CODE PG 36)
LIST ALL COVERING COLLEAGUES THAT ARE NOT PARTNERS/ASSOCIATES AT THIS PRACTICE
SPECIALTY CODE
LAST NAME
M.I.
FIRST NAME
covering colleagues
that are not partners at
Covering Colleagues
to check “Primary
Location” at the top of
the page.
COVERING
COLLEAGUE
(Y/N)?
SPECIALTY CODE
LAST NAME
Covering
Colleagues
SPECIALTY CODE
FIRST NAME
COVERING
COLLEAGUE
(Y/N)?
SPECIALTY CODE
LAST NAME
M.I.
FIRST NAME
SPECIALTY CODE
LAST NAME
M.I.
FIRST NAME
Section 5
Hospital Affiliations
Admitting
Arrangements
DO YOU HAVE
HOSPITAL
PRIVILEGES?*
YES
NO
IF YOU DO NOT ADMIT PATIENTS, WHAT
TYPE OF ADMITTING ARRANGEMENTS DO
YOU HAVE?
3087
Page 11
Std. App. v.5.0
Section 5
Hospital Affiliations (Continued)
Hospital
Privileges
PRIMARY HOSPITAL
If applicable, list all
hospital affiliations. List
primary hospital, then
other current
affiliations, followed by
previous affiliations in
chronological order.
HOSPITAL NAME
NUMBER
STREET
SUITE/BUILDING
CITY
hospital privileges, use
the Supplemental
Hospital Privileges
Form on page 30.
STATE
-
-
-
TELEPHONE
ZIP CODE
-
FAX
DEPARTMENT NAME
DEPARTMENT DIRECTOR’S LAST NAME
DEPARTMENT DIRECTOR’S FIRST NAME
M M
TIP Be certain your
admission percentages
add up to 100% for
current hospitals.
Otherwise, you will
have to correct this
error.
Y Y
Y
M.I.
Y
M M Y
AFFILIATION START DATE
Y
Y
Y
FULL, UNRESTRICTED
PRIVILEGES?
YES
NO
ARE PRIVILEGES
TEMPORARY?
YES
NO
AFFILIATION END DATE
OF YOUR TOTAL ANNUAL
ADMISSIONS, WHAT PERCENTAGE
IS TO THIS HOSPITAL?
%
ADMITTING PRIVILEGE STATUS (E.G. NONE, FULL UNRESTRICTED, PROVISIONAL, TEMPORARY)
OTHER HOSPITAL
HOSPITAL NAME
NUMBER
STREET
SUITE/BUILDING
CITY
STATE
-
-
-
TELEPHONE
ZIP CODE
-
FAX
DEPARTMENT NAME
M.I.
M M
Y Y
Y
Y
M M Y
Y
Y
Y
FULL, UNRESTRICTED
PRIVILEGES?
YES
NO
ARE PRIVILEGES
TEMPORARY?
YES
NO
%
PLEASE EXPLAIN
TERMINATED AFFILIATION
3088
Page 12
Std. App. v.5.0
Section 6
Professional
Liability
Insurance
Carrier
IMPORTANT
IF YOU DO NOT
CARRY
MALPRACTICE
INSURANCE, CHECK
THIS BOX AND SKIP
THIS SECTION.
Professional Liability Insurance Carrier
YES
SELF-INSURED?*
NO
CARRIER OR SELF-INSURED NAME*
NUMBER*
STREET*
SUITE/BUILDING
CITY*
M M Y
STATE*
Y
Y
Y
M M Y
ORIGINAL EFFECTIVE DATE*
Y
Y
Y
M M Y
EFFECTIVE DATE*
DO YOU HAVE UNLIMITED COVERAGE
WITH THIS INSURANCE CARRIER?*
YES
Y
Y
Y
YES
INDIVIDUAL
SHARED
EXPIRATION DATE
NO
$
,
$
,
AMOUNT OF COVERAGE PER OCCURRENCE
POLICY INCLUDES TAIL COVERAGE?
ZIP CODE*
TYPE OF
COVERAGE?*
,
,
AMOUNT OF COVERAGE AGGREGATE
NO
POLICY NUMBER*
Professional
Liability
Insurance
Carrier
List other current,
future, or previous
carrier(s) if current
carrier is less than ten
(10) years.
NOTE: A longer period
may be required by
your healthcare entity.
Insurance, use the
Supplemental
Insurance Form on
page 31.
YES
SELF-INSURED?
NO
CARRIER OR SELF-INSURED NAME
NUMBER*
STREET*
SUITE/BUILDING
CITY*
M M Y
STATE*
Y
Y
Y
M M Y
Y
Y
Y
M M Y
EFFECTIVE DATE*
WITH THIS INSURANCE CARRIER?
YES
Y
Y
Y
YES
TYPE OF
COVERAGE?*
INDIVIDUAL
SHARED
EXPIRATION DATE
NO
$
,
$
,
ZIP CODE*
,
,
NO
POLICY NUMBER*
Section 7
Work History and References
Military
Duty
Are you currently on active military
duty or military reserve?*
Work History
WORK HISTORY
Include a chronological
work history for the
past 10 years.
PRACTICE / EMPLOYER NAME
A longer period may be
required by your
healthcare entity.
NUMBER
work history, use the
Supplemental Work
History Form on page
32.
YES
NO
STREET
SUITE/BUILDING
CITY
STATE
ZIP/POSTAL CODE
3089
Page 13
Std. App. v.5.0
Section 7
Work History and References (Continued)
Work History
Do not list current
positions. Those
should be listed in
Section 4.
Include a chronological
work history for the
past 10 years.
-
-
-
TELEPHONE
-
FAX
M M Y
COUNTRY CODE
Y
Y
Y
START DATE
M M Y
Y
Y
Y
END DATE
REASON FOR DEPARTURE (IF APPLICABLE)
A longer period may be
required by your
healthcare entity
work history, use the
Supplemental Work
History Form on page
32.
WORK HISTORY
NUMBER
STREET
SUITE/BUILDING
CITY
STATE
-
-
-
TELEPHONE
ZIP/POSTAL CODE
-
FAX
M M Y
COUNTRY CODE
Y
Y
Y
START DATE
M M Y
Y
Y
Y
END DATE
WORK HISTORY
NUMBER
STREET
SUITE/BUILDING
CITY
STATE
-
-
-
TELEPHONE
-
FAX
M M Y
COUNTRY CODE
ZIP/POSTAL CODE
START DATE
Y
Y
Y
M M Y
Y
Y
Y
END DATE
3090
Page 14
Std. App. v.5.0
Section 7
Gaps in
Professional /
Work History
Work History and References (Continued)
PLEASE EXPLAIN ANY TIME PERIODS OR GAPS IN TRAINING OR WORK HISTORY THAT HAVE OCCURRED SINCE GRADUATION FROM PROFESSIONAL SCHOOL AND ARE
LONGER THAN THREE MONTHS IN DURATION OR OF A SHORTER DURATION IF REQUIRED BY THE ORGANIZATION FOR WHICH YOU ARE BEING CREDENTIALED.
M M Y
GAP START DATE
Y
Y
Y
GAP END DATE
M M Y
Y
Y
Y
professional / work
history gaps, use the
Supplemental
Professional Work
History Gaps Form on
page 33.
Professional
References
LAST NAME*
Provide three
professional references
to whom you are not
related or are not
partners in your
practice.
FIRST NAME*
NUMBER*
for provider type.
Please check with
credentialing entity for
any special
requirements.
APT/SUITE/BUILDING
CITY*
STATE*
-
NOTE:
You are required to
provide exactly 3
references. Your
application will not be
complete without this
information.
STREET*
-
TELEPHONE
-
ZIP CODE*
-
FAX
LAST NAME*
FIRST NAME*
NUMBER*
STREET*
APT/SUITE/BUILDING
CITY*
STATE*
-
-
TELEPHONE
-
ZIP CODE*
-
FAX
LAST NAME*
FIRST NAME*
NUMBER*
STREET*
APT/SUITE/BUILDING
CITY*
STATE*
TELEPHONE
-
-
ZIP CODE*
-
FAX
3091
Page 15
Std. App. v.5.0
Section 8
Disclosure
Questions
Answer all questions.
For any “Yes”
response, provide an
explanation on the
Supplemental
Disclosure Question
Explanation Form on
page 34.
Disclosure Questions
LICENSURE
YES
NO
2.
YES
NO Has there been any challenge to your licensure, registration or certification?*
HOSPITAL PRIVILEGES AND OTHER AFFILIATIONS
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?*
3.
YES
NO
4.
YES
NO Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?*
5.
YES
NO Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action,
Allied Health
Providers
If you are an Allied
Health Provider and
you do not believe a
question is applicable
to you, you should
answer the question
“NO”.
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?*
1.
by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)?*
EDUCATION, TRAINING AND BOARD CERTIFICATION
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?*
6.
YES
NO
7.
YES
NO Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status
8.
YES
NO
9.
YES
NO Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?*
as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?*
Have any of your board certifications or eligibility ever been revoked?*
DEA OR STATE CONTROLLED SUBSTANCE REGISTRATION
10.
YES
NO
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?*
MEDICARE, MEDICAID OR OTHER GOVERNMENTAL PROGRAM PARTICIPATION
11.
YES
NO
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?*
OTHER SANCTIONS OR INVESTIGATIONS
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?*
12.
YES
NO
13.
YES
NO
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.
YES
NO
Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies (e.g., CLIA,
OSHA, etc.)?*
15.
YES
NO
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?*
16.
YES
NO
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?*
PROFESSIONAL LIABILITY INSURANCE INFORMATION AND CLAIMS HISTORY
17.
YES
NO
Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your
individual liability history?*
18.
YES
NO
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?*
3092
Page 16
Std. App. v.5.0
Section 8
Disclosure
Questions
Answer all questions.
For any “Yes”
response, provide an
explanation on the
Supplemental
Disclosure Question
Explanation Form on
page 34.
Disclosure Questions (Continued)
MALPRACTICE CLAIMS HISTORY
19.
YES
NO
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.
CRIMINAL/CIVIL HISTORY
20.
YES
NO Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony?*
21.
YES
NO traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, compe-
In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor
IMPORTANT
If you answered “Yes”
to question #19, you
must complete the
Supplemental
Malpractice Claims
Explanation Form on
page 35 for each
malpractice claim.
tence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offense or sexual
misconduct?*
22.
YES
NO Have you ever been court-martialed for actions related to your duties as a medical professional?*
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 the relevant circumstances, including the nature of the crime.
ABILITY TO PERFORM JOB
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.)
23.
YES
NO
24.
YES
NO Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the func-
25.
YES
NO Do you have any reason to believe that you would pose a risk to the safety or well being of your patients?*
26.
YES
NO Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonable
tions of your job with reasonable skill and safety?*
accommodation?*
3093
Page 17
Std. App. v.5.0
Standard Authorization, Attestation and Release
(Not for Use for Employment Purposes)
I understand and agree that, as part of the credentialing application process for participation, membership and/or clinical privileges (hereinafter, referred to as
"Participation") at or with each healthcare organization indicated on the "List of Authorized Organizations" that accompanies this Provider Application (hereinafter,
each healthcare organization on the "List of Authorized Organizations" is 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, employ ees, 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.
Authorization of Investigation Concerning Application for Participation. I 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 designat ed 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 and copy all records and documents
relating to such an investigation.
Authorization of 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.
Authorization of 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 pro ceedings 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.
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.
I certify that all information provided by me in my application is current, true, correct, accurate and complete to the best of my knowledge and belief, and is furnished
in good faith. I will notify the Entity and/or its Agent(s) within 10 days of any material changes to the information (including any changes/challenges to licenses, DEA,
insurance, malpractice claims, NPDB/HIPDB reports, discipline, criminal convictions, etc.) 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 online or in writing, and must be dated and signed by me (may be a written or an electronic signature). I acknowledge that the Entity will not process an
application until they deem it to be a complete application and that I am responsible to provide a complete application and to produce adequate and timely informa tion for resolving questions that arise in the application process. 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 acknowledge that I have read and understand the foregoing Authorization, Attestation and Release
and that I have access to the bylaws of applicable medical staff organizations and agree to abide by these bylaws, rules and regulations. I understand and agree that
a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.
Signature*
Name (print)*
M M D D Y
Y
Y
Y
DATE SIGNED*
3094
Page 18
*
Std. App. v.5.0
Professional IDs
Supplemental Form
Section 1
* REQUIRED RESPONSE (IF THIS PAGE IS USED). NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
Personal Information and Professional IDs
Professional
IDs
M M D D Y
FEDERAL DEA NUMBER
DEA ISSUE DATE
Include all additional
state licenses, DEA
Registration and State
Controlled Dangerous
Substance (CDS)
certification numbers.
DEA EXPIRATION DATE
Provide all current and
previous licenses/
certifications.
FEDERAL DEA NUMBER
DEA ISSUE DATE
DEA EXPIRATION DATE
If you need to report
additional Professional
IDs, photocopy this
page as needed and
submit as instructed.
M M D D Y
M M D D Y
M M D D Y
M M D D Y
CDS ISSUE DATE
CDS EXPIRATION DATE
CDS ISSUE DATE
CDS EXPIRATION DATE
M M D D Y
M M D D Y
M M D D Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
M M D D Y
YES
NO
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
LICENSE ISSUE DATE
M M D D Y
LICENSE STATUS CODE
LICENSE TYPE
M M D D Y
YES
NO
LICENSE ISSUE DATE
M M D D Y
LICENSE STATUS CODE
LICENSE TYPE
3095
Page 19
Std. App. v.5.0
Other Relevant Education
Supplemental Form
Section 2
Fifth Pathway
Education
FIFTH PATHWAY GRADUATES ONLY
INSTITUTION/HOSPITAL WHERE U.S. CLINICAL TRAINING WAS PERFORMED (DO NOT ABBREVIATE)
ADDRESS
CITY
STATE
-
-
-
TELEPHONE
ZIP CODE
-
FAX
EDUCATION AT THIS SCHOOL?
YES
M M Y
NO
Y
Y
Y
START DATE
M M Y
Y Y
Y
Other Relevant
Education
INSTITUTION/SCHOOL ISSUING DEGREE (DO NOT ABBREVIATE)
additional Education,
photocopy this page as
needed and submit as
instructed.
NUMBER
STREET
SUITE/BUILDING
CITY
STATE
-
-
-
TELEPHONE
ZIP/POSTAL CODE
-
FAX
M M Y
Y Y
Y
START DATE
COUNTRY CODE
M M Y
Y
Y
Y
YES
DEGREE AWARDED
NO
INSTITUTION/SCHOOL ISSUING DEGREE (DO NOT ABBREVIATE)
NUMBER
STREET
SUITE/BUILDING
CITY
STATE
-
-
-
TELEPHONE
-
FAX
M M Y
COUNTRY CODE
ZIP/POSTAL CODE
Y Y
Y
START DATE
M M Y
Y
Y
Y
YES
DEGREE AWARDED
NO
3079
Page 20
Std. App. v.5.0
Other Training
Supplemental Form
Section 2
Training
List all postgraduate
training programs you
attended. Use one
section per institution.
additional Training,
instructed.
SCHOOL CODE (E.G.,
AFFILIATED MEDICAL
SCHOOL)
INSTITUTION / HOSPITAL NAME (USE BOTH LINES IF REQUIRED)
NUMBER
STREET
SUITE/BUILDING
CITY
STATE
COUNTRY CODE
ZIP/POSTAL CODE
-
-
TELEPHONE
DID YOU COMPLETE THIS TRAINING PROGRAM AT THIS
INSTITUTION?
-
FAX
YES
NO
OTHER
M M
(IF NOT, PLEASE USE THE SPACE BELOW TO EXPLAIN.)
List each
department
separately, if
applicable.
List
Internship/
Residency,
Fellowship
and Other
programs
separately.
INTERNSHIP/
RESIDENCY
FELLOWSHIP
Y
Y
Y
Y
START DATE
M M
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
END DATE
NAME OF DIRECTOR
INTERNSHIP/
RESIDENCY
FELLOWSHIP
OTHER
M M
Y
Y
Y
Y
START DATE
M M
END DATE
NAME OF DIRECTOR
INTERNSHIP/
RESIDENCY
FELLOWSHIP
OTHER
M M
START DATE
Y
Y
Y
Y
M M
END DATE
NAME OF DIRECTOR
3096
Page 21
Std. App. v.5.0
Additional Specialty
Supplemental Form
*
Section 3
Additional
Specialty
REQUIRED RESPONSE (IF THIS PAGE IS USED). NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
Professional / Medical Specialty Information
SPECIALTY
CODE
BOARD
CERTIFIED?
YES
NO
CERTIFYING
BOARD
CODE
IF NOT
BOARD
CERTIFIED
(SELECT
ONE)
INITIAL
CERTIFICATION
DATE
M M D D Y
Y
Y
Y
RECERTIFICATION
DATE
(IF APPLICABLE)
M M D D Y
Y
Y
Y
EXPIRATION DATE
(IF APPLICABLE)
M M D D Y
Y
Y
Y
I HAVE TAKEN
EXAM, RESULTS
PENDING FOR
EXAM ON
M M D D Y
DO YOU WISH TO
BE LISTED IN
THE DIRECTORY
UNDER THIS
SPECIALTY?
HMO
YES
NO
PPO
YES
NO
POS
YES
NO
HMO
YES
NO
PPO
YES
NO
POS
YES
NO
A CERTIFYING BOARD EXAM
Y
Y
Y
Additional
Specialty
additional Specialties,
instructed.
SPECIALTY
CODE
BOARD
CERTIFIED?
YES
NO
CERTIFYING
BOARD
CODE
IF NOT
BOARD
CERTIFIED
(SELECT
ONE)
I HAVE TAKEN
EXAM, RESULTS
PENDING FOR
INITIAL
CERTIFICATION
DATE
M M D D Y
Y
Y
Y
RECERTIFICATION
DATE
(IF APPLICABLE)
M M D D Y
Y
Y
Y
EXPIRATION DATE
(IF APPLICABLE)
M M D D Y
Y
Y
Y
EXAM ON
M M D D Y
DO YOU WISH TO
BE LISTED IN
THE DIRECTORY
UNDER THIS
SPECIALTY?
Y
Y
Y
3097
Page 22
Std. App. v.5.0
Partners/Associates
Supplemental Form
Section 4
Partner/
Associates
Use this page to
report additional
the designated
practice location.
SPECIFY PRACTICE LOCATION
LOCATION #
INDICATE THE PRACTICE LOCATION TO WHICH YOU ARE ASSOCIATING THESE PROVIDERS.
PRIMARY PRACTICE
PRACTICE NAME
PRACTICE ADDRESS
IMPORTANT
In the box provided,
indicate to which
practice location this
page belongs.
LAST NAME
SPECIALTY CODE
FIRST NAME
Check “Covering
Colleague?” if he/she
provides coverage for
you at THIS location.
Code lists are found
on pages 36-43. Enter
the associated 3-digit
code in the space
provided.
additional
partners/associates,
photocopy this page
as needed and submit
as instructed.
M.I.
LAST NAME
SPECIALTY CODE
FIRST NAME
M.I.
LAST NAME
M.I.
LAST NAME
M.I.
LAST NAME
M.I.
LAST NAME
M.I.
LAST NAME
M.I.
LAST NAME
M.I.
COVERING
COLLEAGUE
(Y/N)?
SPECIALTY CODE
FIRST NAME
COVERING
COLLEAGUE
(Y/N)?
SPECIALTY CODE
FIRST NAME
COVERING
COLLEAGUE
(Y/N)?
SPECIALTY CODE
FIRST NAME
COVERING
COLLEAGUE
(Y/N)?
SPECIALTY CODE
FIRST NAME
COVERING
COLLEAGUE
(Y/N)?
SPECIALTY CODE
FIRST NAME
COVERING
COLLEAGUE
(Y/N)?
SPECIALTY CODE
FIRST NAME
COVERING
COLLEAGUE
(Y/N)?
COVERING
COLLEAGUE
(Y/N)?
3098
Page 23
Std. App. v.5.0
Covering Colleagues
Supplemental Form
Section 4
Covering
Colleagues
Include all colleagues
providing regular
coverage and his/her
specialty, including if
he/she is a partner in
one or more of your
practice locations.
IMPORTANT
indicate to which
page belongs.
additional Covering
Colleagues, photocopy
this page as needed
and submit as
instructed.
SPECIFY PRACTICE LOCATION
LOCATION #
INDICATE THE PRACTICE LOCATION TO WHICH YOU ARE ASSOCIATING THESE PROVIDERS.
PRIMARY PRACTICE
PRACTICE NAME
PRACTICE ADDRESS
LAST NAME
SPECIALTY CODE
M.I.
FIRST NAME
LAST NAME
SPECIALTY CODE
FIRST NAME
M.I.
SPECIALTY CODE
LAST NAME
FIRST NAME
M.I.
LAST NAME
SPECIALTY CODE
FIRST NAME
M.I.
LAST NAME
SPECIALTY CODE
FIRST NAME
M.I.
LAST NAME
SPECIALTY CODE
M.I.
FIRST NAME
SPECIALTY CODE
LAST NAME
FIRST NAME
M.I.
SPECIALTY CODE
LAST NAME
FIRST NAME
M.I.
3099
Page 24
Std. App. v.5.0
Supplemental Form
Section 4
Additional
Practice
Location
Practice Location Information - Page 1 of 5
LOCATION*
CURRENTLY
PRACTICING AT
THIS ADDRESS?*
#
YES
NO
PREVIOUS
OR FUTURE
START DATE?
M M D D Y Y
Y
Y
IMPORTANT
indicate to which
page belongs.
For example, if you
practice at three
locations, the primary
location is reported in
the main application
and remaining
locations would be
reported on
Supplemental Forms
as Location 2 and
Location 3.
PHYSICIAN GROUP / PRACTICE NAME TO APPEAR IN DIRECTORY (DO NOT ABBREVIATE)*
GROUP / CORPORATE NAME AS IT APPEARS ON W-9, IF DIFFERENT FROM ABOVE (DO NOT ABBREVIATE)
NUMBER*
STREET*
SUITE/BUILDING
CITY*
SEND GENERAL
CORRESPONDENCE HERE?*
YES
-
NO
-
TELEPHONE*
TIP Your Individual Tax
ID is assumed to be
your Primary Tax ID
unless you specify
otherwise to the right.
Office Manager
or Business
Office Contact
List each contact
separately. You may
use the check boxes
below for convenience.
Do not write
instructions like “see
above”. These
responses will be
rejected and will
require follow-up.
STATE*
ZIP CODE*
-
-
FAX
OFFICE E-MAIL ADDRESS
-
-
-
INDIVIDUAL TAX ID
PRIMARY
TAX ID
(ONE ONLY)*
-
USE INDIVIDUAL
TAX ID
USE GROUP
TAX ID
GROUP TAX ID
LAST NAME*
FIRST NAME*
M.I.
-
-
TELEPHONE*
-
-
FAX
E-MAIL ADDRESS
Billing Contact
LAST NAME*
CHECK HERE TO
USE OFFICE
MANAGER AND
OFFICE ADDRESS
AS BILLING
INFORMATION
M.I.
FIRST NAME*
NUMBER*
NOTE:
Even if you checked
the boxes above,
please provide the
e-mail address of the
Billing Contact, if
available.
STREET*
SUITE/BUILDING
STATE*
CITY*
TELEPHONE*
-
-
ZIP CODE*
-
FAX
E-MAIL ADDRESS
3100
Page 25
Std. App. v.5.0
Supplemental Form
Section 4
Add’l Practice
Location (Cont.)
Payment and
Remittance
#
LOCATION*
ELECTRONIC
BILLING
CAPABILITIES?*
YES
NO
BILLING DEPARTMENT (IF HOSPITAL-BASED)
YOUR “CHECK PAYABLE TO”
INFORMATION SHOULD BE
CONSISTENT WITH YOUR
W-9.
CHECK HERE TO
USE OFFICE
MANAGER AND
OFFICE ADDRESS
AS BILLING
INFORMATION
CHECK PAYABLE TO*
LAST NAME*
M.I.
FIRST NAME*
NUMBER*
STREET*
SUITE/BUILDING
NOTE:
Even if you checked
the boxes above,
please provide the
E-mail Address,
Department Name,
Electronic Billing and
Check Payable To, if
applicable.
CITY*
Office Hours
(USE HHMM FORMAT AND ROUND TO THE NEAREST HALF-HOUR)
STATE*
-
-
After hours back office
telephone will be used
only by the health plan
and will not be
published under any
circumstances.
Open Practice
Status
-
FAX
E-MAIL ADDRESS
A=AM
P=PM
START
NOTE:
-
TELEPHONE*
ZIP CODE*
A=AM
P=PM
END
START
MONDAY
FRIDAY
TUESDAY
SATURDAY
WEDNESDAY
SUNDAY
A=AM
P=PM
A=AM
P=PM
END
THURSDAY
24/7 PHONE COVERAGE?*
YES
NO
IF YES
AFTER HOURS BACK OFFICE TELEPHONE
VOICE MAIL WITH
INSTRUCTIONS TO CALL
ANSWERING SERVICE
ANSWERING
SERVICE
VOICE MAIL
WITH OTHER
INSTRUCTIONS
-
-
ACCEPT NEW PATIENTS INTO THIS PRACTICE?*
YES
NO
ACCEPT ALL NEW PATIENTS?*
YES
NO
ACCEPT EXISTING PATIENTS WITH CHANGE OF PAYOR?*
YES
NO
ACCEPT NEW MEDICARE PATIENTS?*
YES
NO
ACCEPT NEW PATIENTS WITH PHYSICIAN REFERRAL?*
YES
NO
ACCEPT NEW MEDICAID PATIENTS?*
YES
NO
IF ANY OF THE
ABOVE VARIES BY
PLAN, EXPLAIN
ARE THERE ANY
PRACTICE LIMITATIONS?*
YES
NO
GENDER LIMITATIONS
IF YES
MALE
ONLY
AGE LIMITATIONS
NONE
LIST OTHER LIMITATIONS
MINIMUM
AGE
MAXIMUM
AGE
FEMALE
ONLY
3101
Page 26
Std. App. v.5.0
Supplemental Form
Section 4
Additional
Practice
Location
(Continued)
LOCATION*
#
DO MID-LEVEL PRACTITIONERS (NURSE PRACTITIONERS, PHYSICIAN
ASSISTANTS, ETC.) CARE FOR PATIENTS IN YOUR PRACTICE?*
YES
NO
IMPORTANT
(IF YES, PLEASE PROVIDE THE INFORMATION BELOW)
indicate to which
page belongs.
M.I.
CNP, NP)
M.I.
CNP, NP)
M.I.
CNP, NP)
M.I.
CNP, NP)
M.I.
CNP, NP)
Mid-Level
Practitioners
PRACTITIONER STATE
PRACTITIONER STATE
PRACTITIONER STATE
PRACTITIONER STATE
PRACTITIONER STATE
3102
Page 27
Std. App. v.5.0
Supplemental Form
Section 4
Additional
Practice
Location
(Continued)
LOCATION*
#
LANGUAGES
NON-ENGLISH LANGUAGES
SPOKEN BY OFFICE PERSONNEL
IMPORTANT
indicate to which
page belongs.
Accessibilities
LANGUAGE CODE
INTERPRETERS
AVAILABLE?*
YES
NO
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGES
INTERPRETED
DOES THIS OFFICE MEET ADA ACCESSIBILITY REQUIREMENTS?*
DOES THIS SITE OFFER HANDICAPPED
ACCESS FOR THE FOLLOWING
YES
NO
DOES THIS SITE OFFER OTHER
SERVICES FOR THE DISABLED?*
YES
NO
ACCESSIBLE BY
PUBLIC TRANSPORTATION?*
YES
NO
BUILDING?*
YES
NO
TEXT TELEPHONY (TTY)*
YES
NO
BUS*
YES
NO
PARKING?*
YES
NO
AMERICAN SIGN LANGUAGE*
YES
NO
SUBWAY*
YES
NO
RESTROOM?*
YES
NO
MENTAL/PHYSICAL IMPAIRMENT
SERVICES*
YES
NO
REGIONAL TRAIN*
YES
NO
OTHER HANDICAPPED ACCESS
Services
LANGUAGE CODE
OTHER TRANSPORTATION ACCESS
OTHER DISABILITY SERVICES
Does this location provide any of the following services?
LABORATORY
SERVICES?
YES
NO
IF YES, PROVIDE ACCREDITING/
CERTIFYING PROGRAM
(E.G., CLIA, COLA, MLE)
RADIOLOGY
SERVICES?
YES
NO
IF YES, PROVIDE X-RAY
CERTIFICATION TYPE
EKGS?
YES
NO
ALLERGY
INJECTIONS?
YES
NO
ALLERGY SKIN
TESTING?
YES
NO
ROUTINE OFFICE
GYNECOLOGY
(PELVIC/PAP)?
YES
NO
DRAWING
BLOOD?
YES
NO
AGE
APPROPRIATE
IMMUNIZATIONS?
YES
NO
FLEXIBLE
SIGMOIDOSCOPY?
YES
NO
TYMPANOMETR
Y/ AUDIOMETRY
SCREENING?
YES
NO
ASTHMA
TREATMENT?
YES
NO
OSTEOPATHIC
MANIPULATION?
YES
NO
IV HYDRATION/
TREATMENT?
YES
NO
CARDIAC
STRESS TEST?
YES
NO
YES
NO
PHYSICAL
THERAPY?
YES
NO
CARE OF MINOR
LACERATIONS?
YES
NO
YES
NO
IF YES, WHAT
CLASS/CATEGORY
DO YOU USE?
PULMONARY
FUNCTION
TESTING?
IS ANESTHESIA
ADMINISTERED IN
YOUR OFFICE?
IF YES, WHO
ADMINISTERS IT?
LAST NAME
TYPE OF PRACTICE
(SELECT ONE ONLY)*
FIRST NAME
SOLO PRACTICE
SINGLE SPECIALTY GROUP
MULTI-SPECIALTY GROUP
ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)
3103
Page 28
Std. App. v.5.0
Supplemental Form
Section 4
Additional
Practice
Location
(Continued)
LOCATION*
#
LIST ALL PARTNERS/ASSOCIATES AT THIS PRACTICE
IMPORTANT
indicate to which
page belongs.
SPECIALTY CODE
LAST NAME
M.I.
FIRST NAME
Partner/Associate
to indicate the Practice
Location Number at the
top of the page.
M.I.
FIRST NAME
LAST NAME
M.I.
LAST NAME
covering colleagues
that are not partners at
Covering Colleagues
to indicate the Practice
Location Number at the
top of the page.
M.I.
COVERING
COLLEAGUE
(Y/N)?
SPECIALTY CODE
FIRST NAME
COVERING
COLLEAGUE
(Y/N)?
SPECIALTY CODE
FIRST NAME
Covering
Colleagues
SPECIALTY CODE
LAST NAME
COVERING
COLLEAGUE
(Y/N)?
COVERING
COLLEAGUE
(Y/N)?
LIST ALL COVERING COLLEAGUES THAT ARE NOT PARTNERS/ASSOCIATES AT THIS PRACTICE
LAST NAME
SPECIALTY CODE
FIRST NAME
M.I.
SPECIALTY CODE
LAST NAME
M.I.
FIRST NAME
SPECIALTY CODE
LAST NAME
FIRST NAME
M.I.
SPECIALTY CODE
LAST NAME
FIRST NAME
M.I.
3104
Page 29
Std. App. v.5.0
Hospital Privileges (Current)
Supplemental Form
Section 5
Hospital Affiliations
Hospital
Privileges
OTHER HOSPITAL
Use this form to
continue listing
hospitals where you
currently have
privileges.
HOSPITAL NAME
additional space for
Hospital Privileges,
instructed.
TIP Be certain your
admission percentages
add up to 100% for
current hospitals.
Otherwise, you will
have to correct this
error.
NUMBER
STREET
SUITE/BUILDING
CITY
STATE
-
-
-
TELEPHONE
ZIP CODE
-
FAX
DEPARTMENT NAME
M.I.
M M Y
Y
Y
Y
M M
Y Y
Y
Y
FULL, UNRESTRICTED
PRIVILEGES?
YES
NO
ARE PRIVILEGES
TEMPORARY?
YES
NO
%
PLEASE EXPLAIN
TERMINATED AFFILIATION
THIS SPACE HAS BEEN PURPOSELY LEFT BLANK
3105
Page 30
Std. App. v.5.0
Supplemental Form
*
Section 6
Other
Professional
Liability
Insurance
Carrier
List secondary /
second layer / future or
previous carrier(s).
For second layer
coverage list name of
hospital/organization
providing coverage
YES
SELF-INSURED?
NO
NUMBER*
STREET*
SUITE/BUILDING
CITY*
M M Y
STATE*
Y
Y
Y
M M Y
Y
Y
Y
EFFECTIVE DATE*
YES
M M Y
Y
Y
Y
YES
TYPE OF
COVERAGE?*
INDIVIDUAL
SHARED
EXPIRATION DATE
NO
$
,
$
,
ZIP CODE*
,
,
NO
POLICY NUMBER*
Other
Professional
Liability
Insurance
Carrier
List secondary /
second layer / future or
previous carrier(s).
For second layer
coverage list name of
hospital/organization
providing coverage
If you need additional
space for Insurance
Coverage, photocopy
this page as needed
and submit as
instructed.
YES
SELF-INSURED?
NO
NUMBER*
STREET*
SUITE/BUILDING
CITY*
M M Y
Y
Y
Y
M M Y
Y
Y
Y
M M Y
EFFECTIVE DATE*
YES
Y
Y
YES
ZIP CODE*
TYPE OF
COVERAGE?*
INDIVIDUAL
SHARED
EXPIRATION DATE
NO
$
,
,
Y
STATE*
$
,
,
NO
POLICY NUMBER*
3106
Page 31
Std. App. v.5.0
Work History
Supplemental Form
*
REQUIRED RESPONSE (IF THIS PAGE IS USED). NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
Section 7
Work History
Work History
WORK HISTORY
Use this form to
continue listing work
history.
space for Work History,
instructed.
NUMBER
STREET
SUITE/BUILDING
CITY
STATE
-
-
-
TELEPHONE
ZIP/POSTAL CODE
-
FAX
M M Y
COUNTRY CODE
Y
Y
Y
START DATE
M M Y
Y
Y
Y
END DATE
WORK HISTORY
NUMBER
STREET
SUITE/BUILDING
CITY
STATE
-
-
-
TELEPHONE
-
FAX
M M Y
COUNTRY CODE
ZIP/POSTAL CODE
START DATE
Y
Y
Y
M M Y
Y
Y
Y
END DATE
3107
Page 32
Std. App. v.5.0
Professional Training / Work History Gaps
Supplemental Form
Section 7
Professional
Training /
Work History
Gaps
Please explain any
time periods or gaps in
training or work history
that have occurred
since graduation from
professional school
and are longer than
three month in duration
or of a shorter duration
if required by the
organization for which
you are being
credentialed.
Professional Training / Work History Gaps
GAP START DATE
M M Y
Y
Y
Y
GAP END DATE
M M Y Y
Y
Y
GAP START DATE
M M Y
Y
Y
Y
GAP END DATE
M M Y Y
Y
Y
GAP START DATE
M M Y
Y
Y
Y
GAP END DATE
M M Y Y
Y
Y
GAP START DATE
M M Y
Y
Y
Y
GAP END DATE
M M Y Y
Y
Y
GAP START DATE
M M Y
Y
Y
Y
GAP END DATE
M M Y Y
Y
Y
3108
Page 33
Std. App. v.5.0
Supplemental Form
Section 8
Disclosure
Questions
QUESTION #
EXPLANATION
QUESTION #
EXPLANATION
QUESTION #
EXPLANATION
Use this form to report
any “Yes” response to
one or more of the
in Section 8. Your
response should not
exceed the spaces
provided.
Record the question
number in the first
column, then your
explanation in the
second column.
space to explain a Yes
response, photocopy
this page as needed
and submit as
instructed.
3109
Page 34
Std. App. v.5.0
Malpractice Claims Explanation
Supplemental Form
Section 8
Malpractice
Claims
Explanation
Malpractice Claims Explanation
DATE OF
OCCURRENCE*
M M D D Y
Y
Y
DATE CLAIM
WAS FILED*
Y
M M D D Y
Y
Y
Y
M M D D Y
Y
Y
Y
STATUS OF CLAIM* (NOTE: IF CASE IS PENDING, SELECT OPEN)
Use this form to report
any “Yes” response to
Disclosure Question
#19.
space to explain a Yes
response, photocopy
this page as needed
and submit as
instructed.
OPEN
IF SETTLED, ENTER DATE
CLAIM WAS SETTLED
CLOSED
PROFESSIONAL LIABILITY CARRIER INVOLVED* (USE BOTH LINES IF NECESSARY)
NUMBER*
STREET*
SUITE/BUILDING
CITY*
STATE*
-
-
TELEPHONE
$
ZIP CODE*
POLICY NUMBER
,
METHOD OF
RESOLUTION?*
,
DISMISSED
SETTLED
JUDGMENT FOR
DEFENDANT(S)
JUDGMENT FOR
PLAINTIFF(S)
MEDIATION
ARBITRATION
AMOUNT OF AWARD OR SETTLEMENT*
DESCRIPTION OF ALLEGATIONS* (USE ALL FOUR LINES BELOW, IF NECESSARY)
WERE YOU THE PRIMARY
DEFENDANT OR CO-DEFENDANT?*
PRIMARY
DEFENDANT
CO-DEFENDANT
NUMBER OF OTHER
CO-DEFENDANTS (IF ANY)
YOUR INVOLVEMENT IN CASE* (ATTENDING, CONSULTING, ETC)
DESCRIPTION OF ALLEGED INJURY TO THE PATIENT (USE ALL FOUR LINES BELOW, IF NECESSARY)
DID THE ALLEGED INJURY
RESULT IN DEATH?
YES
NO
TO THE BEST OF YOUR KNOWLEDGE, IS THE CASE INCLUDED
IN THE NATIONAL PRACTITIONER DATA BANK (NPDB)?*
YES
NO
3110
Page 35
Std. App. v.5.0
Code Lists
Provider Type Codes
001 Medical Doctor (MD)
002 Doctor of Dental Surgery (DDS)
003 Doctor of Dental Medicine (DMD)
004 Doctor of Podiatric Medicine (DPM)
005 Doctor of Chiropractic (DC)
007 Osteopathic Doctor (DO)
020
021
022
023
024
025
026
027
028
029
Acupuncturist
Alcohol/Drug Counselor
Audiologist
Biofeedback Technician
Certified Registered Nurse
Anesthetist
Christian Science Practitioner
Clinical Nurse Specialist
Clinical Psychologist
Clinical Social Worker
Dietician
030
031
032
033
034
035
036
037
038
039
040
Licensed Practical Nurse
Marriage/Family Therapist
Massage Therapist
Naturopath
Neuropsychologist
Midwife
Nurse Midwife
Nurse Practitioner
Nutritionist
Occupational Therapist
Optician
041
042
043
044
045
046
047
048
049
Optometrist
Pharmacist
Physical Therapist
Physician Assistant
Professional Counselor
Registered Nurse
Registered Nurse First Assistant
Respiratory Therapist
Speech Pathologist
008
009
010
011
012
013
014
Pending
Probation
Provisional
Restricted
Revoked
Suspended
Surrendered
015
016
017
018
019
Temporary
Terminated
Time Limited
Unrestricted
Other
174
178
180
184
188
384
191
192
196
203
208
262
212
214
626
218
818
222
226
232
233
231
238
234
242
246
250
249
254
258
260
266
270
268
276
288
292
300
304
308
312
316
320
324
624
328
332
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (provisional)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadaloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
334 Heard Island and McDonald
Islands
340 Honduras
344 Hong Kong
348 Hungary
352 Iceland
356 India
360 Indonesia
364 Iran
368 Iraq
372 Ireland
376 Israel
380 Italy
388 Jamaica
392 Japan
400 Jordan
398 Kazakhstan
404 Kenya
296 Kiribati
408 Korea, North
410 Korea, South
414 Kuwait
417 Kyrgyzstan
418 Laos
428 Latvia
422 Lebanon
426 Lesotho
430 Liberia
434 Libya
438 Liechtenstein
440 Lithuania
442 Luxembourg
446 Macau
807 Macedonia
450 Madagascar
454 Malawi
458 Malaysia
462 Maldives
466 Mali
470 Malta
584 Marshall Islands
474 Martinique
478 Mauritania
480 Mauritius
175 Mayotte
484 Mexico
583 Micronesia
License Status Codes
001
002
003
004
005
006
007
Active
Canceled
Denied
Expired
Inactive
Lapsed
Limited
Country Codes
004
008
012
016
020
024
660
010
028
032
051
533
036
040
031
044
048
050
052
112
056
084
204
060
064
068
070
072
074
076
086
096
100
854
108
116
120
124
132
136
140
148
152
156
162
166
170
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
498
492
496
500
504
508
104
516
520
524
528
530
540
554
558
562
566
570
574
580
578
512
586
585
591
598
600
604
608
612
616
620
630
634
638
642
643
646
654
659
662
666
670
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the
Grenadines
Page 36
Std. App. v.5.0
Code Lists
Country Codes (continued)
882
674
678
682
683
686
690
694
702
703
705
090
706
710
239
Samoa
San Marino
São Tomé and Príncipe
Saudi Arabia
Scotland
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South
724
144
736
740
744
748
752
756
760
158
762
834
764
768
Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
772
776
780
788
792
796
798
800
804
784
826
840
581
858
860
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey795
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
U.S. Minor Outlying Islands
Uruguay
Uzbekistan
061
062
063
064
065
066
067
068
069
070
071
072
073
074
075
076
077
078
079
080
081
082
083
084
085
086
087
088
089
090
091
092
093
094
095
096
097
098
099
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
Kinyarwanda
Kirghiz
Kurundi
Korean
Kurdish
Laothian
Latin
Latvian;Lettish
Lingala
Lithuanian
Macedonian
Malagasy
Malay
Malayalam
Maltese
Maori
Marathi
Moldavian
Mongolian
Nauru
Nepali
Norwegian
Occitan
Oriya
Pashto;Pushto
Persian (Farsi)
Polish
Portuguese
Punjabi
Quechua
Rhaeto-Romance
Romanian
Russian
Samoan
Sangho
Sanskrit
Scot Gaelic
Serbian
Serbo-Croatian
Sesotho
Setswana
Shona
Sindhi
Singhalese
Siswati
Slovak
Slovenian
Somali
Spanish
Sundanese
Swahili
Swedish
Tagalog
Tajik
Tamil
Tatar
Telugu
Thai
Tibetan
Tigrinya
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
10
137
138
Tonga
Tsonga
Turkish
Turkmen
Twi
Uigur
Ukrainian
Urdu
Uzbek
Vietnamese
Volapuk
Welsh
Wolof
Xhosa
Yiddish
Yoruba
Zerbaijani
Zhuang
Zulu
548
336
862
704
092
850
876
732
887
891
894
716
Vanuatu
Vatican City State (Holy See)
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Fortuna Islands
Western Sahara (provisional)
Yemen
Yugoslavia
Zambia
Zimbabwe
Language Codes
001
002
003
004
005
006
007
008
009
010
011
012
013
014
015
016
017
018
019
020
021
022
023
024
025
026
027
028
140
030
031
032
033
034
035
036
037
038
039
040
041
042
043
044
045
046
047
048
049
050
051
052
053
054
055
056
057
058
059
060
Abkhazian
Afan (Oromo)
Afar
Afrikaans
Albanian
Amharic
Arabic
Armenian
Assamese
Zerbaijani
Bashkir
Basque
Bengali;Bangla
Bhutani
Bihari
Bislama
Breton
Bulgarian
Burmese
Byelorussian
Cambodian
Catalan
Chinese
Corsican
Croatian
Czech
Danish
Dutch
English
Esperonto
Estonian
Faroese
Fiji
Finnish
French
Frisian
Galican
Georgian
German
Greek
Greenlandic
Guarani
Gujarati
Hausa
Hebrew
Hindi
Hungarian
Icelandic
Indonesian
Interlingua
Interlingue
Inuktitut
Inupiak
Irish
Italian
Japanese
Javanese
Kannada
Kashmiri
Kazakh
Page 37
Std. App. v.5.0
Code Lists
U.S. / Canadian Professional School Codes
Alabama
300 University of Alabama School of Dentistry
001 University of Alabama School of Medicine
002 University of South Alabama College of Medicine
Arkansas
003 University of Arkansas College of Medicine
Arizona
500 Arizona College of Osteopathic Medicine
004 University of Arizona College of Medicine
California
801 California College of Podiatric Medicine
400 Cleveland Chiropractic College of Los Angele
005 Keck School of Medicine
401 Life Chiropractic College West
301 Loma Linda University School of Dentistry
006 Loma Linda University School of Medicine
402 Los Angeles College of Chiropractic
403 Palmer College of Chiropractic West
404 Quantum University/SCCC
007 Stanford University School of Medicine
501 Touro University College of Osteopathic Medicine
008 UCLA School of Medicine
009 University of California
010 University of California, Irvine, College of Medicine
302 University of California, Los Angeles School of Dentistry
011 University of California, San Diego, School of Medicine
303 University of California, San Francisco, School of Dentistry
012 University of California, San Francisco, School of Medicine
304 University of Southern California School of Dentistry
305 University of the Pacific School of Dentistry
502 Western University of Health Sciences, College of Osteopathic Medicine
of the Pacific
Colorado
306 University of Colorado School of Dentistry
013 University of Colorado School of Medicine
Connecticut
405 University of Bridgeport College of Chiropractic
307 University of Connecticut School of Dental Medicine
014 University of Connecticut School of Medicine
015 Yale University School of Medicine
District of Columbia
016 George Washington University
017 Georgetown University School of Medicine
308 Howard University College of Dentistry
018 Howard University College of Medicine
Florida
800 Barry University School of Graduate Medical Sciences
309 Nova Southeastern University College of Dentistry
503 Nova Southeastern University College of Osteopathic Medicine
310 University of Florida College of Dentistry
019 University of Florida College of Medicine
020 University of Miami School of Medicine
021 University of South Florida College of Medicine
Georgia
022 Emory University School of Medicine
406 Life Chiropractic College
311 Medical College of Georgia School of Dentistry
023 Medical College of Georgia School of Medicine
024 Mercer University School of Medicine
025 Morehouse School of Medicine
Hawaii
026 John A. Burns School of Medicine
Iowa
802 College of Podiatric Medicine and Surgery Des Moines University
504 Des Moines University, Osteopathic Medical Center, College of
Osteopathic Medicine and Surgery
407 Palmer College of Chiropractic
312 University of Iowa College of Dentistry
027 University of Iowa College of Medicine
Illinois
028 Chicago Medical School, Finch University of Health Sciences
029 Loyola University Chicago, Stritch School of Medicine
505 Midwestern University, Chicago College of Osteopathic Medicine
408 National College of Chiropractic
313 Northwestern University Dental School
030 Northwestern University Medical School
031 Rush Medical College of Rush University
804 Scholl College of Podiatric Medicine at Finch University
314 Southern Illinois University School of Dental Medicine
032 Southern Illinois University School of Medicine
033 University of Chicago, The Pritzker School of Medicine
315 University of Illinois at Chicago College of Dentistry
034 University of Illinois College of Medicine
Indiana
316 Indiana University School of Dentistry
035 Indiana University School of Medicine
Kansas
036 University of Kansas School of Medicine
Kentucky
506 Pikeville College, School of Osteopathic Medicine
317 University of Kentucky College of Dentistry
037 University of Kentucky College of Medicine
318 University of Louisville School of Dentistry
038 University of Louisville School of Medicine
Louisiana
319 Louisiana State University School of Dentistry
039 Louisiana State University School of Medicine in New Orleans
040 Louisiana State University School of Medicine in Shreveport
041 Tulane University School of Medicine
Massachusetts
042 Boston University School of Medicine
320 Boston University, Goldman School of Dental Medicine
043 Harvard Medical School
321 Harvard School of Dental Medicine
322 Tufts University School of Dental Medicine
044 Tufts University School of Medicine
045 University of Massachusetts Medical School
Maryland
046 Johns Hopkins University School of Medicine
047 Uniformed Services University of the Health Sciences
048 University of Maryland School of Medicine
323 University of Maryland, Baltimore, College of Dental Surgery
Maine
507 University of New England, College of Osteopathic Medicine
Michigan
049 Michigan State University College of Human Medicine
508 Michigan State University, College of Osteopathic Medicine
324 University of Detroit Mercy School of Dentistry
050 University of Michigan Medical School
325 University of Michigan School of Dentistry
051 Wayne State University School of Medicine
Minnesota
052 Mayo Medical School
409 Northwestern College of Chiropractic
053 University of Minnesota, Duluth School of Medicine
054 University of Minnesota Medical School, Twin Cities
326 University of Minnesota School of Dentistry
Missouri
410 Cleveland Chiropractic College of Kansas City
509 Kirksville College of Osteopathic Medicine
411 Logan Chiropractic College
055 Saint Louis University School of Medicine
510 University of Health Sciences, College of Osteopathic Medicine
056
327
057
058
University of Missouri, Columbia School of Medicine
University of Missouri Kansas City School of Dentistry
University of Missouri Kansas City School of Medicine
Washington University in St. Louis School of Medicine
Page 38
Std. App. v.5.0
Code Lists
U.S. / Canadian Professional School Codes (continued)
Mississippi
328 University of Mississippi School of Dentistry
059 University of Mississippi School of Medicine
North Carolina
060 Duke University School of Medicine
061 The Brody School of Medicine at East Carolina University
329 University of North Carolina at Chapel Hill School of Dentistry
062 University of North Carolina at Chapel Hill School of Medicine
063 Wake Forest University School of Medicine
North Dakota
064 University of North Dakota School of Medicine and Health Sciences
Nebraska
330 Creighton University School of Dentistry
065 Creighton University School of Medicine
066 University of Nebraska College of Medicine
331 University of Nebraska Medical Center, College of Dentistry
New Hampshire
067 Dartmouth Medical School
New
068
069
332
511
Jersey
Robert Wood Johnson Medical School
University of Medicine and Dentistry of New Jersey (UMDNJ)
UMDNJ, New Jersey Dental School
UMDNJ, School of Osteopathic Medicine
New Mexico
070 University of New Mexico School of Medicine
Nevada
071 University of Nevada School of Medicine
New
072
073
074
333
075
076
412
512
077
334
078
335
082
336
081
079
080
083
Ohio
337
084
085
086
803
338
087
513
088
089
York
Albany Medical College
Albert Einstein College of Medicine
Columbia University College of Physicians and Surgeons
Columbia University School of Dental and Oral Surgery
Joan & Sanford I. Weill Medical College of Cornell University
Mount Sinai School of Medicine of New York University
New York Chiropractic College
NY College of Osteopathic Medicine of the NY Institute of Technology
New York Medical College
New York University Kriser Dental Center
New York University School of Medicine
State University of New York at Buffalo School of Dental Medicine
State University of New York at Buffalo School of Medicine
State University of New York at Stony Brook School of Dental Medicine
State University of New York at Stony Brook School of Medicine
State University of New York College of Medicine
State University of New York Upstate Medical University
University of Rochester School of Medicine and Dentistry
Case Western Reserve University School of Dentistry
Case Western Reserve University School of Medicine
Medical College of Ohio
Northeastern Ohio Universities College of Medicine
Ohio College of Podiatric Medicine
Ohio State University College of Dentistry
Ohio State University College of Medicine and Public Health
Ohio University College of Osteopathic Medicine
University of Cincinnati College of Medicine
Wright State University School of Medicine
Oklahoma
514 Oklahoma State University, College of Osteopathic Medicine
339 University of Oklahoma College of Dentistry
090 University of Oklahoma College of Medicine
Oregon
091 Oregon Health & Science University School of Medicine
340 Oregon Health Sciences University School of Dentistry
413 Western States Chiropractic College
Pennsylvania
092 Jefferson Medical College of Thomas Jefferson University
515
093
094
516
341
095
805
342
096
343
097
Lake Erie College of Osteopathic Medicine
MCP Hahnemann University School of Medicine
Pennsylvania State University College of Medicine
Philadelphia College of Osteopathic Medicine
Temple University School of Dentistry
Temple University School of Medicine
Temple University School of Podiatric Medicine
University of Pennsylvania School of Dental Medicine
University of Pennsylvania School of Medicine
University of Pittsburgh School of Dental Medicine
University of Pittsburgh School of Medicine
Puerto Rico
098 Ponce School of Medicine
099 Universidad Central del Caribe School of Medicine
100 University of Puerto Rico School of Medicine
344 University of Puerto Rico School of Dentistry
Rhode Island
101 Brown Medical School
South Carolina
345 Medical University of South Carolina College of Dental Medicine
102 Medical University of South Carolina College of Medicine
414 Sherman College of Chiropractic
103 University of South Carolina School of Medicine
South Dakota
104 University of South Dakota School of Medicine
Tennessee
105 East Tennessee State University
346 Meharry Medical College School of Dentistry
106 Meharry Medical College School of Medicine
347 University of Tennessee College of Dentistry
107 University of Tennessee College of Medicine
108 Vanderbilt University School of Medicine
Texas
348 Baylor College of Dentistry
109 Baylor College of Medicine
415 Parker College of Chiropractic
416 Texas Chiropractic College
110 Texas Tech University Health Sciences Center School of Medicine
111 The Texas A & M University System College of Medicine
517 UNT Health Sciences Center, Texas College of Osteopathic Medicine
349 University of Texas Health Science Center at Houston Dental School
350 University of Texas Health Science Center at San Antonio Dental School
112 University of Texas Medical Branch at Galveston
113 University of Texas Medical School at Houston
114 University of Texas Medical School at San Antonio
115 UT Southwestern Medical Center at Dallas Southwestern Medical School
Utah
116 University of Utah School of Medicine
Virginia
117 Eastern VA Medical School of the Medical College of Hampton Roads
118 University of Virginia School of Medicine Health System
351 Virginia Commonwealth University School of Dentistry
119 Virginia Commonwealth University School of Medicine
Vermont
120 University of Vermont College of Medicine
Washington
352 University of Washington School of Dentistry
121 University of Washington School of Medicine
Wisconsin
353 Marquette University School of Dentistry
122 Medical College of Wisconsin
123 University of Wisconsin Medical School
West Virginia
124 Joan C. Edwards School of Medicine at Marshall University
518 West Virginia School of Osteopathic Medicine
354 West Virginia University School of Dentistry
125 West Virginia University School of Medicine
Page 39
Std. App. v.5.0
Code Lists
U.S. / Canadian Professional School Codes (continued)
Canada
355 Dalhousie University Faculty of Dentistry
126 Dalhousie University Faculty of Medicine
357 Laval University Faculty of Dentistry
127 Laval University Faculty of Medicine
356 McGill University Faculty of Dentistry
128 McGill University Faculty of Medicine
129 McMaster University School of Medicine
130 Memorial University of Newfoundland Faculty of Medicine
131 Queen's University Faculty of Health Sciences
132 The University of Western Ontario Faculty of Medicine & Dentistry
133 Universite de Montreal Faculty of Medicine
134 Universite de Sherbrooke Faculty of Medicine
358 University of Alberta Faculty of Dentistry
135 University of Alberta Faculty of Medicine
359 University of British Columbia Faculty of Dentistry
136 University of British Columbia Faculty of Medicine
137 University of Calgary Faculty of Medicine
360 University of Manitoba Faculty of Dentistry
138 University of Manitoba Faculty of Medicine
361 University of Montreal Faculty of Dentistry
139 University of Ottawa Faculty of Medicine
362 University of Saskatchewan College of Dentistry
140 University of Saskatchewan College of Medicine
363 University of Toronto Faculty of Dentistry
141 University of Toronto Faculty of Medicine
364 University of Western Ontario Faculty of Dentistry
Specialty Codes - MD / DO Only
NOTE: THIS LIST IS FROM THE NATIONAL HEALTH CARE PROVIDER TAXONOMY CODE LIST, PUBLISHED IN COOPERATION WITH THE NATIONAL UNIFORM CLAIM COMMITTEE (NUCC).
247 Allergy & Immunology
246 Allergy & Immunology, Allergy
291 Allergy & Immunology, Clinical &
Laboratory Immunology
249 Anesthesiology
235 Anesthesiology, Addiction Medicine
258 Anesthesiology, Critical Care Medicine
126 Anesthesiology, Pain Medicine
363 Clinical Pharmacology
367 Colon & Rectal Surgery
263 Dermatology
292 Dermatology, Clinical & Laboratory
Dermatological Immunology
444 Dermatology, Dermatological Surgery
266 Dermatology, Dermatopathology
264 Dermatology, MOHS-Micrographic Surgery
443 Dermatology, Pediatric Dermatology
268 Emergency Medicine
445 Emergency Medicine, Emergency Medical
Services
427 Emergency Medicine, Medical Toxicology
348 Emergency Medicine, Pediatric Emergency
Medicine
395 Emergency Medicine, Sports Medicine
446 Emergency Medicine, Undersea and Hyperbaric
Medicine
391 Facial Plastic Surgery
272 Family Practice
447 Family Practice, Addiction Medicine
237 Family Practice, Adolescent Medicine
448 Family Practice, Adult Medicine
282 Family Practice, Geriatric Medicine
396 Family Practice, Sports Medicine
225 General Practice
479 Hospitalist
301 Internal Medicine
449 Internal Medicine, Addiction Medicine
236 Internal Medicine, Adolescent Medicine
248 Internal Medicine, Allergy & Immunology
255 Internal Medicine, Cardiovascular Disease
294 Internal Medicine, Clinical & Laboratory
Immunology
253 Internal Medicine, Clinical Cardiac
Electrophysiology
257 Internal Medicine, Critical Care Medicine
267 Internal Medicine, Endocrinology, Diabetes &
Metabolism
275 Internal Medicine, Gastroenterology
285 Internal Medicine, Geriatric Medicine
287
288
450
299
451
453
325
309
378
390
397
433
481
278
261
277
280
455
454
306
308
409
330
440
317
318
315
316
321
260
326
286
303
320
271
328
441
411
412
456
406
415
Internal Medicine, Hematology
Internal Medicine, Hematology & Oncology
Internal Medicine, Hepatology
Internal Medicine, Infectious Disease
Internal Medicine, Interventional Cardiology
Internal Medicine, Magnetic Resonance Imaging
(MRI)
Internal Medicine, Medical Oncology
Internal Medicine, Nephrology
Internal Medicine, Pulmonary Disease
Internal Medicine, Rheumatology
Internal Medicine, Sports Medicine
Laboratories, Clinical Medical Laboratory
Legal Medicine
Medical Genetics, Clinical Biochemical Genetics
Medical Genetics, Clinical Cytogenetic
Medical Genetics, Clinical Genetics (M.D.)
Medical Genetics, Clinical Molecular Genetics
Medical Genetics, Molecular Genetic Pathology
Medical Genetics, Ph.D. Medical Genetics
Neonatal-Perinatal Medicine
Neopathology
Neurological Surgery
Neuromusculoskeletal Medicine & OMM
Neuromusculoskeletal Medicine, Sports Medicine
Nuclear Medicine
Nuclear Medicine, In Vivo & In Vitro Nuclear
Medicine
Nuclear Medicine, Nuclear Cardiology
Nuclear Medicine, Nuclear Imaging & Therapy
Obstetrics & Gynecology
Obstetrics & Gynecology, Critical Care Medicine
Obstetrics & Gynecology, Gynecologic Oncology
Obstetrics & Gynecology, Gynecology
Obstetrics & Gynecology, Maternal & Fetal
Medicine
Obstetrics & Gynecology, Obstetrics
Obstetrics & Gynecology, Reproductive
Endocrinology
Ophthalmology
Oral & Maxillofacial Surgery
Orthopaedic Surgery
Orthopaedic Surgery, Adult Reconstructive
Orthopaedic Surgery
Orthopaedic Surgery, Foot and Ankle
Orthopaedics
Orthopaedic Surgery, Hand Surgery
Orthopaedic Surgery, Orthopaedic Surgery of the
Spine
416
457
119
331
458
459
332
357
417
480
337
338
340
250
344
Orthopaedic Surgery, Orthopaedic Trauma
Orthopaedic Surgery, Sports Medicine
Orthopedic
Otolaryngology
Otolaryngology, Otolaryngic Allergy
Otolaryngology, Otolaryngology/ Facial Plastic
Surgery
Otolaryngology, Otology & Neurotology
Otolaryngology, Pediatric Otolaryngology
Otolaryngology, Plastic Surgery within the Head
& Neck
Pain Medicine, Interventional Pain Medicine
Pain Medicine
Pathology, Anatomic Pathology
Pathology, Anatomic Pathology & Clinical
Pathology
Pathology, Blood Banking & Transfusion
Medicine
Pathology, Chemical Pathology
302 Pathology, Clinical
Pathology/Laboratory Medicine
262 Pathology, Cytopathology
265 Pathology, Dermatopathology
273 Pathology, Forensic Pathology
290 Pathology, Hematology
298 Pathology, Immunopathology
305 Pathology, Medical Microbiology
461 Pathology, Molecular Genetic
Pathology
312 Pathology, Neuropathology
358 Pathology, Pediatric Pathology
244 Pediatrics
239 Pediatrics, Adolescent Medicine
295 Pediatrics, Clinical & Laboratory
Immunology
462 Pediatrics, Developmental –
Behavioral Pediatrics
354 Pediatrics, Medical Toxicology
356 Pediatrics, Neurodevelopmental
Disabilities
345 Pediatrics, Pediatric Allergy &
Immunology
346 Pediatrics, Pediatric Cardiology
347 Pediatrics, Pediatric Critical Care
Medicine
463 Pediatrics, Pediatric Emergency
Medicine
349 Pediatrics, Pediatric Endocrinology
Page 40
Std. App. v.5.0
Code Lists
Specialty Codes - MD/DO Only
350 Pediatrics, Pediatric
Gastroenterology
351 Pediatrics, Pediatric HematologyOncology
352 Pediatrics, Pediatric Infectious
Diseases
355 Pediatrics, Pediatric Nephrology
359 Pediatrics, Pediatric Pulmonology
361 Pediatrics, Pediatric Rheumatology
398 Pediatrics, Sports Medicine
365 Physical Medicine & Rehabilitation
468 Physical Medicine & Rehabilitation,
Pain Medicine
Pediatric Rehabilitation Medicine
Spinal Cord Injury Medicine
Sports Medicine
419 Plastic Surgery
470 Plastic Surgery, Plastic Surgery
Within the Head and Neck
407 Plastic Surgery, Surgery of the
Hand
242 Preventive Medicine, Aerospace
Medicine
429 Preventive Medicine, Medical
Toxicology
112 Preventive Medicine, Occupational
Medicine
471 Preventive Medicine, Sports
Medicine
431 Preventive Medicine, Undersea
and Hyperbaric Medicine
114 Preventive Medicine/Occupational
Environmental Medicine
370 Psychiatry & Neurology, Addiction
Medicine
473 Psychiatry & Neurology, Addiction
Psychiatry
371 Psychiatry & Neurology, Child &
Adolescent Psychiatry
313 Psychiatry & Neurology, Clinical
Neurophysiology
274 Psychiatry & Neurology, Forensic
Psychiatry
373 Psychiatry & Neurology, Geriatric
Psychiatry
472 Psychiatry & Neurology,
Neurodevelopmental Disabilities
100 Psychiatry & Neurology, Neurology
311 Psychiatry & Neurology, Neurology
with Special Qualifications in Child
Neurology
474 Psychiatry & Neurology, Pain
Medicine
368 Psychiatry & Neurology, Psychiatry
475 Psychiatry & Neurology, Sports
Medicine
476 Psychiatry & Neurology, Vascular
Neurology
366 Public Health & General Preventive
Medicine
252 Radiology, Body Imaging
173 Radiology, Diagnostic Radiology
430 Radiology, Diagnostic Ultrasound
314 Radiology, Neuroradiology
319 Radiology, Nuclear Radiology
360 Radiology, Pediatric Radiology
380 Radiology, Radiation Oncology
477 Radiology, Radiological Physics
381 Radiology, Therapeutic Radiology
384 Radiology, Vascular &
Interventional Radiology
434 Supplier
399 Surgery
418 Surgery, Pediatric Surgery
420 Surgery, Plastic and Reconstructive
Surgery
405 Surgery, Surgery of the Hand
425 Surgery, Surgical Critical Care
413 Surgery, Surgical Oncology
423 Surgery, Trauma Surgery
400 Surgery, Vascular Surgery
421 Thoracic Surgery (Cardiothoracic
Vascular Surgery)
442 Transplant Surgery
424 Urology
Specialty Codes - DDS / DMD / DPM / DC
DDS / DMD
2
Dentist
13
Dentist, Dental Public Health
14
Dentist, Endodontics
438 Dentist, General Practice
16
Dentist, Oral and Maxillofacial Pathology
439 Dentist, Oral and Maxillofacial Radiology
20
Dentist, Oral and Maxillofacial Surgery
15
Dentist, Orthodontics and Dentofacial Orthopedics
17
Dentist, Pediatric Dentistry
18
Dentist, Periodontics
19
Dentist, Prosthodontics
DPM
3
231
230
225
227
226
228
229
Podiatrist
Podiatrist, Foot & Ankle Surgery
Podiatrist, Foot Surgery
Podiatrist, General Practice
Podiatrist, Primary Podiatric Medicine
Podiatrist, Public Medicine
Podiatrist, Radiology
Podiatrist, Sports Medicine
DC
1
5
6
7
8
9
10
11
12
Chiropractor
Chiropractor, Internist
Chiropractor, Neurology
Chiropractor, Nutrition
Chiropractor, Occupational Medicine
Chiropractor, Orthopedic
Chiropractor, Radiology
Chiropractor, Sports Physician
Chiropractor, Thermography
Specialty Codes - Allied Providers
501
503
504
505
531
727
728
729
730
731
732
733
734
735
736
737
738
739
740
741
742
743
744
745
746
747
748
749
750
751
752
Acupuncturist
Audiologist
Audiologist, Assistive Technology Practitioner
Audiologist, Assistive Technology Supplier
Christian Science Practitioner
Clinical Nurse Specialist
Clinical Nurse Specialist, Acute Care
Clinical Nurse Specialist, Adult Health
Clinical Nurse Specialist, Chronic Care
Clinical Nurse Specialist, Community Health/Public Health
Clinical Nurse Specialist, Critical Care Medicine
Clinical Nurse Specialist, Emergency
Clinical Nurse Specialist, Ethics
Clinical Nurse Specialist, Family Health
Clinical Nurse Specialist, Gerontology
Clinical Nurse Specialist, Holistic
Clinical Nurse Specialist, Home Health
Clinical Nurse Specialist, Informatics
Clinical Nurse Specialist, Long-Term Care
Clinical Nurse Specialist, Medical-Surgical
Clinical Nurse Specialist, Neonatal
Clinical Nurse Specialist, Neuroscience
Clinical Nurse Specialist, Occupational Health
Clinical Nurse Specialist, Oncology
Clinical Nurse Specialist, Oncology, Pediatrics
Clinical Nurse Specialist, Pediatrics
Clinical Nurse Specialist, Perinatal
Clinical Nurse Specialist, Perioperative
Clinical Nurse Specialist, Psychiatric/Mental Health
Clinical Nurse Specialist, Psychiatric/Mental Health, Adult
Clinical Nurse Specialist, Psychiatric/Mental Health, Child & Adolescent
753
754
755
756
757
759
758
760
513
514
515
516
533
536
534
535
651
517
547
549
652
551
553
653
654
655
656
658
657
659
Clinical Nurse Specialist, Psychiatric/Mental Health, Child & Family
Clinical Nurse Specialist, Psychiatric/Mental Health, Chronically Ill
Clinical Nurse Specialist, Psychiatric/Mental Health, Community
Clinical Nurse Specialist, Psychiatric/Mental Health, Geropsychiatric
Clinical Nurse Specialist, Rehabilitation
Clinical Nurse Specialist, School
Clinical Nurse Specialist, Transplantation
Clinical Nurse Specialist, Women's Health
Counselor
Counselor, Addiction (Substance Use Disorder)
Counselor, Mental Health
Counselor, Professional
Dietitian, Registered
Dietitian, Registered, Nutrition, Metabolic
Dietitian, Registered, Nutrition, Pediatric
Dietitian, Registered, Nutrition, Renal
Licensed Practical Nurse
Marriage & Family Therapist
Massage Therapist
Midwife, Certified
Midwife, Certified Nurse
Naturopath
Neuropsychologist
Nurse Anesthetist, Certified Registered
Nurse Practitioner
Nurse Practitioner, Acute Care
Nurse Practitioner, Adult Health
Nurse Practitioner, Community Health
Nurse Practitioner, Critical Care Medicine
Nurse Practitioner, Family
Page 41
Std. App. v.5.0
Code Lists
Specialty Codes - Allied Providers (continued)
660
661
662
670
671
663
664
666
667
665
668
669
537
538
555
556
557
558
559
560
561
563
565
566
567
571
568
569
570
573
574
575
576
577
578
580
581
583
582
584
585
586
587
590
588
589
592
593
594
596
597
598
599
602
600
601
603
604
605
606
607
608
609
610
611
612
613
614
615
672
673
674
711
681
676
677
678
680
679
Nurse Practitioner, Gerontology
Nurse Practitioner, Neonatal
Nurse Practitioner, Neonatal, Critical Care
Nurse Practitioner, Obstetrics & Gynecology
Nurse Practitioner, Occupational Health
Nurse Practitioner, Pediatrics
Nurse Practitioner, Pediatrics, Critical Care
Nurse Practitioner, Perinatal
Nurse Practitioner, Primary Care
Nurse Practitioner, Psych/Mental Health
Nurse Practitioner, School
Nurse Practitioner, Women's Health
Nutritionist
Nutritionist, Nutrition, Education
Occupational Therapist
Occupational Therapist, Ergonomics
Occupational Therapist, Hand
Occupational Therapist, Human Factors
Occupational Therapist, Neurorehabilitation
Occupational Therapist, Pediatrics
Occupational Therapist, Rehabilitation, Driver
Optician
Optometrist
Optometrist, Corneal and Contact Management
Optometrist, Low Vision Rehabilitation
Optometrist, Occupational Vision
Optometrist, Pediatrics
Optometrist, Sports Vision
Optometrist, Vision Therapy
Pharmacist
Pharmacist, General Practice
Pharmacist, Nuclear Pharmacy
Pharmacist, Nutrition Support
Pharmacist, Pharmacotherapy
Pharmacist, Psychopharmacy
Physical Therapist
Physical Therapist, Cardiopulmonary
Physical Therapist, Electrophysiology, Clinical
Physical Therapist, Ergonomics
Physical Therapist, Geriatrics
Physical Therapist, Hand
Physical Therapist, Human Factors
Physical Therapist, Neurology
Physical Therapist, Orthopedic
Physical Therapist, Pediatrics
Physical Therapist, Sports
Physician Assistant
Physician Assistant, Medical
Physician Assistant, Surgical
Psychologist
Psychologist, Addiction (Substance Use Disorder)
Psychologist, Adult Development & Aging
Psychologist, Behavioral
Psychologist, Child, Youth & Family
Psychologist, Clinical
Psychologist, Counseling
Psychologist, Educational
Psychologist, Exercise & Sports
Psychologist, Family
Psychologist, Forensic
Psychologist, Health
Psychologist, Men & Masculinity
Psychologist, Mental Retardation & Developmental Disabilities
Psychologist, Psychoanalysis
Psychologist, Psychotherapy
Psychologist, Psychotherapy, Group
Psychologist, Rehabilitation
Psychologist, School
Psychologist, Women
Registered Nurse
Registered Nurse, Addiction (Substance Use Disorder)
Registered Nurse, Administrator
Registered Nurse, Ambulatory Care
Registered Nurse, Cardiac Rehabilitation
Registered Nurse, Case Management
Registered Nurse, College Health
Registered Nurse, Community Health
Registered Nurse, Continence Care
Registered Nurse, Continuing Education/Staff Development
675
682
683
684
685
686
688
687
689
691
690
692
694
693
695
696
697
699
700
701
702
698
703
719
720
721
722
725
724
726
723
704
706
705
710
714
708
709
707
712
713
715
716
718
717
617
618
620
619
622
621
623
628
627
629
624
626
625
630
631
632
634
633
636
635
637
642
641
643
638
640
639
644
646
648
506
649
502
Registered Nurse, Critical Care Medicine
Registered Nurse, Diabetes Educator
Registered Nurse, Dialysis, Peritoneal
Registered Nurse, Emergency
Registered Nurse, Enterostomal Therapy
Registered Nurse, Flight
Registered Nurse, Gastroenterology
Registered Nurse, General Practice
Registered Nurse, Gerontology
Registered Nurse, Hemodialysis
Registered Nurse, Home Health
Registered Nurse, Hospice
Registered Nurse, Infection Control
Registered Nurse, Infusion Therapy
Registered Nurse, Lactation Consultant
Registered Nurse, Maternal Newborn
Registered Nurse, Medical-Surgical
Registered Nurse, Neonatal Intensive Care
Registered Nurse, Neonatal, Low-Risk
Registered Nurse, Nephrology
Registered Nurse, Neuroscience
Registered Nurse, Nurse Massage Therapist (NMT)
Registered Nurse, Nutrition Support
Registered Nurse, Obstetric, High-Risk
Registered Nurse, Obstetric, Inpatient
Registered Nurse, Occupational Health
Registered Nurse, Oncology
Registered Nurse, Ophthalmic
Registered Nurse, Orthopedic
Registered Nurse, Ostomy Care
Registered Nurse, Otorhinolaryngology & Head-Neck
Registered Nurse, Pain Management
Registered Nurse, Pediatric Oncology
Registered Nurse, Pediatrics
Registered Nurse, Perinatal
Registered Nurse, Plastic Surgery
Registered Nurse, Psych/Mental Health
Registered Nurse, Psych/Mental Health, Adult
Registered Nurse, Psych/Mental Health, Child & Adolescent
Registered Nurse, Rehabilitation
Registered Nurse, Reproductive Endocrinology/Infertility
Registered Nurse, School
Registered Nurse, Urology
Registered Nurse, Women's Health Care, Ambulatory
Registered Nurse, Wound Care
Respiratory Therapist, Certified
Respiratory Therapist, Certified, Critical Care
Respiratory Therapist, Certified, Educational
Respiratory Therapist, Certified, Emergency Care
Respiratory Therapist, Certified, General Care
Respiratory Therapist, Certified, Geriatric Care
Respiratory Therapist, Certified, Home Health
Respiratory Therapist, Certified, Neonatal/Pediatrics
Respiratory Therapist, Certified, Palliative/Hospice
Respiratory Therapist, Certified, Patient Transport
Respiratory Therapist, Certified, Pulmonary Diagnostics
Respiratory Therapist, Certified, Pulmonary Function Technologist
Respiratory Therapist, Certified, Pulmonary Rehabilitation
Respiratory Therapist, Certified, SNF/Subacute Care
Respiratory Therapist, Registered
Respiratory Therapist, Registered, Critical Care
Respiratory Therapist, Registered, Educational
Respiratory Therapist, Registered, Emergency Care
Respiratory Therapist, Registered, General Care
Respiratory Therapist, Registered, Geriatric Care
Respiratory Therapist, Registered, Home Health
Respiratory Therapist, Registered, Neonatal/Pediatrics
Respiratory Therapist, Registered, Palliative/Hospice
Respiratory Therapist, Registered, Patient Transport
Respiratory Therapist, Registered, Pulmonary Diagnostics
Respiratory Therapist, Registered, Pulmonary Function Technologist
Respiratory Therapist, Registered, Pulmonary Rehabilitation
Respiratory Therapist, Registered, SNF/Subacute Care
Social Worker, Clinical
Specialist/Technologist, Other, Biomedical Engineering
Speech-Language Pathologist
Technician, Other, Biomedical Engineering
Other, Not Listed
Page 42
Std. App. v.5.0
W-9
Request for Taxpayer
Identification Number and Certification
Form
(Rev. January 2011)
Department of the Treasury
Internal Revenue Service
Give Form to the
requester. Do not
send to the IRS.
Print or type
See Specific Instructions on page 2.
Name (as shown on your income tax return)
Business name/disregarded entity name, if different from above
Check appropriate box for federal tax
classification (required):
Individual/sole proprietor
C Corporation
S Corporation
Partnership
Trust/estate
Exempt payee
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶
Other (see instructions) ▶
Address (number, street, and apt. or suite no.)
Requester’s name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Social security number
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Employer identification number
Part II
–
–
–
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 4.
Sign
Here
Signature of
U.S. person ▶
Date ▶
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Purpose of Form
A person who is required to file an information return with the IRS must
obtain your correct taxpayer identification number (TIN) to report, for
example, income paid to you, real estate transactions, mortgage interest
you paid, acquisition or abandonment of secured property, cancellation
of debt, or contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN to the person requesting it (the
requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a
number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt
payee. If applicable, you are also certifying that as a U.S. person, your
allocable share of any partnership income from a U.S. trade or business
is not subject to the withholding tax on foreign partners’ share of
effectively connected income.
Note. If a requester gives you a form other than Form W-9 to request
your TIN, you must use the requester’s form if it is substantially similar
to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or
business in the United States are generally required to pay a withholding
tax on any foreign partners’ share of income from such business.
Further, in certain cases where a Form W-9 has not been received, a
partnership is required to presume that a partner is a foreign person,
and pay the withholding tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the United
States, provide Form W-9 to the partnership to establish your U.S.
status and avoid withholding on your share of partnership income.
Cat. No. 10231X
Form W-9 (Rev. 1-2011)
Page 2
Form W-9 (Rev. 1-2011)
The person who gives Form W-9 to the partnership for purposes of
establishing its U.S. status and avoiding withholding on its allocable
share of net income from the partnership conducting a trade or business
in the United States is in the following cases:
• The U.S. owner of a disregarded entity and not the entity,
• The U.S. grantor or other owner of a grantor trust and not the trust,
and
• The U.S. trust (other than a grantor trust) and not the beneficiaries of
the trust.
Foreign person. If you are a foreign person, do not use Form W-9.
Instead, use the appropriate Form W-8 (see Publication 515,
Withholding of Tax on Nonresident Aliens and Foreign Entities).
Nonresident alien who becomes a resident alien. Generally, only a
nonresident alien individual may use the terms of a tax treaty to reduce
or eliminate U.S. tax on certain types of income. However, most tax
treaties contain a provision known as a “saving clause.” Exceptions
specified in the saving clause may permit an exemption from tax to
continue for certain types of income even after the payee has otherwise
become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an exemption
from U.S. tax on certain types of income, you must attach a statement
to Form W-9 that specifies the following five items:
1. The treaty country. Generally, this must be the same treaty under
which you claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the
saving clause and its exceptions.
4. The type and amount of income that qualifies for the exemption
from tax.
5. Sufficient facts to justify the exemption from tax under the terms of
the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows an
exemption from tax for scholarship income received by a Chinese
student temporarily present in the United States. Under U.S. law, this
student will become a resident alien for tax purposes if his or her stay in
the United States exceeds 5 calendar years. However, paragraph 2 of
the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows
the provisions of Article 20 to continue to apply even after the Chinese
student becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of the first
protocol) and is relying on this exception to claim an exemption from tax
on his or her scholarship or fellowship income would attach to Form
W-9 a statement that includes the information described above to
support that exemption.
If you are a nonresident alien or a foreign entity not subject to backup
withholding, give the requester the appropriate completed Form W-8.
What is backup withholding? Persons making certain payments to you
must under certain conditions withhold and pay to the IRS a percentage
of such payments. This is called “backup withholding.” Payments that
may be subject to backup withholding include interest, tax-exempt
interest, dividends, broker and barter exchange transactions, rents,
royalties, nonemployee pay, and certain payments from fishing boat
operators. Real estate transactions are not subject to backup
withholding.
You will not be subject to backup withholding on payments you
receive if you give the requester your correct TIN, make the proper
certifications, and report all your taxable interest and dividends on your
tax return.
Payments you receive will be subject to backup
withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the Part II
instructions on page 3 for details),
3. The IRS tells the requester that you furnished an incorrect TIN,
4. The IRS tells you that you are subject to backup withholding
because you did not report all your interest and dividends on your tax
return (for reportable interest and dividends only), or
5. You do not certify to the requester that you are not subject to
backup withholding under 4 above (for reportable interest and dividend
accounts opened after 1983 only).
Certain payees and payments are exempt from backup withholding.
See the instructions below and the separate Instructions for the
Requester of Form W-9.
Also see Special rules for partnerships on page 1.
Updating Your Information
You must provide updated information to any person to whom you
claimed to be an exempt payee if you are no longer an exempt payee
and anticipate receiving reportable payments in the future from this
person. For example, you may need to provide updated information if
you are a C corporation that elects to be an S corporation, or if you no
longer are tax exempt. In addition, you must furnish a new Form W-9 if
the name or TIN changes for the account, for example, if the grantor of a
grantor trust dies.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of $50 for each such failure
unless your failure is due to reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you
make a false statement with no reasonable basis that results in no
backup withholding, you are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal penalties
including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of
federal law, the requester may be subject to civil and criminal penalties.
Specific Instructions
Name
If you are an individual, you must generally enter the name shown on
your income tax return. However, if you have changed your last name,
for instance, due to marriage without informing the Social Security
Administration of the name change, enter your first name, the last name
shown on your social security card, and your new last name.
If the account is in joint names, list first, and then circle, the name of
the person or entity whose number you entered in Part I of the form.
Sole proprietor. Enter your individual name as shown on your income
tax return on the “Name” line. You may enter your business, trade, or
“doing business as (DBA)” name on the “Business name/disregarded
entity name” line.
Partnership, C Corporation, or S Corporation. Enter the entity's name
on the “Name” line and any business, trade, or “doing business as
(DBA) name” on the “Business name/disregarded entity name” line.
Disregarded entity. Enter the owner's name on the “Name” line. The
name of the entity entered on the “Name” line should never be a
disregarded entity. The name on the “Name” line must be the name
shown on the income tax return on which the income will be reported.
For example, if a foreign LLC that is treated as a disregarded entity for
U.S. federal tax purposes has a domestic owner, the domestic owner's
name is required to be provided on the “Name” line. If the direct owner
of the entity is also a disregarded entity, enter the first owner that is not
disregarded for federal tax purposes. Enter the disregarded entity's
name on the “Business name/disregarded entity name” line. If the owner
of the disregarded entity is a foreign person, you must complete an
appropriate Form W-8.
Note. Check the appropriate box for the federal tax classification of the
person whose name is entered on the “Name” line (Individual/sole
proprietor, Partnership, C Corporation, S Corporation, Trust/estate).
Limited Liability Company (LLC). If the person identified on the
“Name” line is an LLC, check the “Limited liability company” box only
and enter the appropriate code for the tax classification in the space
provided. If you are an LLC that is treated as a partnership for federal
tax purposes, enter “P” for partnership. If you are an LLC that has filed a
Form 8832 or a Form 2553 to be taxed as a corporation, enter “C” for
C corporation or “S” for S corporation. If you are an LLC that is
disregarded as an entity separate from its owner under Regulation
section 301.7701-3 (except for employment and excise tax), do not
check the LLC box unless the owner of the LLC (required to be
identified on the “Name” line) is another LLC that is not disregarded for
federal tax purposes. If the LLC is disregarded as an entity separate
from its owner, enter the appropriate tax classification of the owner
identified on the “Name” line.
Page 3
Form W-9 (Rev. 1-2011)
Other entities. Enter your business name as shown on required federal
tax documents on the “Name” line. This name should match the name
shown on the charter or other legal document creating the entity. You
may enter any business, trade, or DBA name on the “Business name/
disregarded entity name” line.
Exempt Payee
If you are exempt from backup withholding, enter your name as
described above and check the appropriate box for your status, then
check the “Exempt payee” box in the line following the “Business name/
disregarded entity name,” sign and date the form.
Generally, individuals (including sole proprietors) are not exempt from
backup withholding. Corporations are exempt from backup withholding
for certain payments, such as interest and dividends.
Note. If you are exempt from backup withholding, you should still
complete this form to avoid possible erroneous backup withholding.
The following payees are exempt from backup withholding:
1. An organization exempt from tax under section 501(a), any IRA, or a
custodial account under section 403(b)(7) if the account satisfies the
requirements of section 401(f)(2),
2. The United States or any of its agencies or instrumentalities,
3. A state, the District of Columbia, a possession of the United States,
or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions, agencies,
or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup withholding include:
6. A corporation,
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register in the
United States, the District of Columbia, or a possession of the United
States,
9. A futures commission merchant registered with the Commodity
Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year under the
Investment Company Act of 1940,
12. A common trust fund operated by a bank under section 584(a),
13. A financial institution,
14. A middleman known in the investment community as a nominee or
custodian, or
15. A trust exempt from tax under section 664 or described in section
4947.
The following chart shows types of payments that may be exempt
from backup withholding. The chart applies to the exempt payees listed
above, 1 through 15.
IF the payment is for . . .
THEN the payment is exempt
for . . .
Interest and dividend payments
All exempt payees except
for 9
Broker transactions
Exempt payees 1 through 5 and 7
through 13. Also, C corporations.
Barter exchange transactions and
patronage dividends
Exempt payees 1 through 5
Payments over $600 required to be Generally, exempt payees
reported and direct sales over
1 through 7 2
1
$5,000
1
2
See Form 1099-MISC, Miscellaneous Income, and its instructions.
However, the following payments made to a corporation and reportable on Form
1099-MISC are not exempt from backup withholding: medical and health care
payments, attorneys' fees, gross proceeds paid to an attorney, and payments for
services paid by a federal executive agency.
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. If you are a resident alien and
you do not have and are not eligible to get an SSN, your TIN is your IRS
individual taxpayer identification number (ITIN). Enter it in the social
security number box. If you do not have an ITIN, see How to get a TIN
below.
If you are a sole proprietor and you have an EIN, you may enter either
your SSN or EIN. However, the IRS prefers that you use your SSN.
If you are a single-member LLC that is disregarded as an entity
separate from its owner (see Limited Liability Company (LLC) on page 2),
enter the owner’s SSN (or EIN, if the owner has one). Do not enter the
disregarded entity’s EIN. If the LLC is classified as a corporation or
partnership, enter the entity’s EIN.
Note. See the chart on page 4 for further clarification of name and TIN
combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately.
To apply for an SSN, get Form SS-5, Application for a Social Security
Card, from your local Social Security Administration office or get this
form online at www.ssa.gov. You may also get this form by calling
1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer
Identification Number, to apply for an ITIN, or Form SS-4, Application for
Employer Identification Number, to apply for an EIN. You can apply for
an EIN online by accessing the IRS website at www.irs.gov/businesses
and clicking on Employer Identification Number (EIN) under Starting a
Business. You can get Forms W-7 and SS-4 from the IRS by visiting
IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676).
If you are asked to complete Form W-9 but do not have a TIN, write
“Applied For” in the space for the TIN, sign and date the form, and give
it to the requester. For interest and dividend payments, and certain
payments made with respect to readily tradable instruments, generally
you will have 60 days to get a TIN and give it to the requester before you
are subject to backup withholding on payments. The 60-day rule does
not apply to other types of payments. You will be subject to backup
withholding on all such payments until you provide your TIN to the
requester.
Note. Entering “Applied For” means that you have already applied for a
TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign owner must
use the appropriate Form W-8.
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or
resident alien, sign Form W-9. You may be requested to sign by the
withholding agent even if item 1, below, and items 4 and 5 on page 4
indicate otherwise.
For a joint account, only the person whose TIN is shown in Part I
should sign (when required). In the case of a disregarded entity, the
person identified on the “Name” line must sign. Exempt payees, see
Exempt Payee on page 3.
Signature requirements. Complete the certification as indicated in
items 1 through 3, below, and items 4 and 5 on page 4.
1. Interest, dividend, and barter exchange accounts opened
before 1984 and broker accounts considered active during 1983.
You must give your correct TIN, but you do not have to sign the
certification.
2. Interest, dividend, broker, and barter exchange accounts
opened after 1983 and broker accounts considered inactive during
1983. You must sign the certification or backup withholding will apply. If
you are subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2 in the
certification before signing the form.
3. Real estate transactions. You must sign the certification. You may
cross out item 2 of the certification.
Page 4
Form W-9 (Rev. 1-2011)
4. Other payments. You must give your correct TIN, but you do not
have to sign the certification unless you have been notified that you
have previously given an incorrect TIN. “Other payments” include
payments made in the course of the requester’s trade or business for
rents, royalties, goods (other than bills for merchandise), medical and
health care services (including payments to corporations), payments to
a nonemployee for services, payments to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of
secured property, cancellation of debt, qualified tuition program
payments (under section 529), IRA, Coverdell ESA, Archer MSA or
HSA contributions or distributions, and pension distributions. You
must give your correct TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account:
Give name and SSN of:
1. Individual
2. Two or more individuals (joint
account)
The individual
The actual owner of the account or,
if combined funds, the first
1
individual on the account
3. Custodian account of a minor
(Uniform Gift to Minors Act)
The minor
4. a. The usual revocable savings
trust (grantor is also trustee)
b. So-called trust account that is
not a legal or valid trust under
state law
5. Sole proprietorship or disregarded
entity owned by an individual
6. Grantor trust filing under Optional
Form 1099 Filing Method 1 (see
Regulation section 1.671-4(b)(2)(i)(A))
For this type of account:
The grantor-trustee
7. Disregarded entity not owned by an
individual
8. A valid trust, estate, or pension trust
The owner
2
The actual owner
The owner
The grantor*
Give name and EIN of:
Legal entity
4
The corporation
13. Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
14. Grantor trust filing under the Form
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulation section 1.671-4(b)(2)(i)(B))
The public entity
2
3
1
3
9. Corporation or LLC electing
corporate status on Form 8832 or
Form 2553
10. Association, club, religious,
charitable, educational, or other
tax-exempt organization
11. Partnership or multi-member LLC
12. A broker or registered nominee
1
1
The organization
The partnership
The broker or nominee
Note. If no name is circled when more than one name is listed, the
number will be considered to be that of the first name listed.
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal information
such as your name, social security number (SSN), or other identifying
information, without your permission, to commit fraud or other crimes.
An identity thief may use your SSN to get a job or may file a tax return
using your SSN to receive a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a
notice from the IRS, respond right away to the name and phone number
printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you
think you are at risk due to a lost or stolen purse or wallet, questionable
credit card activity or credit report, contact the IRS Identity Theft Hotline
at 1-800-908-4490 or submit Form 14039.
For more information, see Publication 4535, Identity Theft Prevention
and Victim Assistance.
Victims of identity theft who are experiencing economic harm or a
system problem, or are seeking help in resolving tax problems that have
not been resolved through normal channels, may be eligible for
Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD
1-800-829-4059.
Protect yourself from suspicious emails or phishing schemes.
Phishing is the creation and use of email and websites designed to
mimic legitimate business emails and websites. The most common act
is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into surrendering
private information that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails. Also, the
IRS does not request personal detailed information through email or ask
taxpayers for the PIN numbers, passwords, or similar secret access
information for their credit card, bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to [email protected]. You may also report misuse
of the IRS name, logo, or other IRS property to the Treasury Inspector
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The trust
List first and circle the name of the person whose number you furnish. If only one person on a
joint account has an SSN, that person’s number must be furnished.
Circle the minor’s name and furnish the minor’s SSN.
You must show your individual name and you may also enter your business or “DBA” name on
the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you
have one), but the IRS encourages you to use your SSN.
4
List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the
personal representative or trustee unless the legal entity itself is not designated in the account
title.) Also see Special rules for partnerships on page 1.
*Note. Grantor also must provide a Form W-9 to trustee of trust.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with
the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation
of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS,
reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District
of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies
to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to
file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a
TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.
DAVIS VISION, INC.
PARTICIPATING PROVIDER AGREEMENT
This PARTICIPATING PROVIDER AGREEMENT (hereinafter “Agreement”) is entered into by
and between DAVIS VISION, INC., (hereinafter “DAVIS”) having its principal place of business
located at 159 Express Street, Plainview, New York 11803 and PARTICIPATING PROVIDER
(hereinafter “PROVIDER”) as defined herein below. DAVIS and PROVIDER are herein referred
to individually as “Party” and collectively as “Parties”.
RECITALS
WHEREAS, DAVIS has entered into or intends to enter into agreements (hereinafter
“Plan Contract(s)”) with health maintenance organizations, Medicare Advantage Program
organizations, Medical Assistance Program organizations, and other purchasers of vision care
services (hereinafter “Plan(s)”); and
WHEREAS, DAVIS has established or shall establish a network of participating
vision care providers (hereinafter “Network”) to provide, or to arrange for the provision of, or in
order to grant access to the vision care services of the Network to individuals (hereinafter
“Members”) who are enrolled as Members of such Plans; and
WHEREAS, the Parties desire to enter into this Agreement whereby PROVIDER
agrees (upon satisfying all Network participation criteria) to provide certain vision care services
(hereinafter “Covered Services”) on behalf of DAVIS to Members of Plans under Plan Contract(s)
with DAVIS.*
NOW, THEREFORE, in consideration of the mutual covenants and promises
contained herein, and intending to be bound hereby, the Parties agree as follows:
I
PREAMBLE AND RECITALS
.1 The preamble and recitals set forth above are hereby incorporated into and
made a part of this Agreement.
II
DEFINITIONS
.1 “Centers for Medicare and Medicaid Services” (hereinafter “CMS”) means the
division of the United States Department of Health and Human Services, formerly known as the
Health Care Financing Administration (HFCA) or any successor agency thereto.
.2 “Clean Claim” means a claim for payment for Covered Services which contains
the following information: (a) a confirmation of eligibility number assigned by DAVIS, referencing
a specific Member and Member’s information; (b) a valid, DAVIS-assigned PROVIDER number;
(c) the date of service; (d) the primary diagnosis code; (e) an indication as to whether or not dilation
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1
Davis Vision, Inc.\Par. Provider Agreement\Standard
was performed; (f) a description of services provided (i.e. examination, materials, etc.); and (g) all
necessary prescription eyewear order information (if applicable). Any claim that does not have all
of the information herein set forth may be pended or denied until all information is received from the
PROVIDER and/or Member. Claims from Participating Providers under investigation for fraud or
abuse and claims submitted with a tax identification number not documented on a properly
completed W-9 form are not Clean Claims. Further, submission of a properly completed CMS Form
1500 or any applicable Uniform Claim Form and any attachments approved or adopted for use in the
applicable jurisdiction for payment of Covered Services and as promulgated by the rules and
regulations of said jurisdiction shall be deemed a Clean Claim.
.3 “Copayment”, “Coinsurance”, or “Deductible” means those charges for vision
care services, which are the responsibility of the Member under a benefit program and which shall
be collected directly by PROVIDER from Member as payment, in addition to the fees paid to
PROVIDER by DAVIS, in accordance with the Member’s benefit program. Such charges are
herein also referred to as “cost sharing” as pertains to charges for which a dually eligible Medicare
Advantage Subscriber is responsible.
.4 “Covered Services” means, except as otherwise provided in the Member’s benefit
plan, a complete and routine eye examination including, but not limited to, visual acuities, internal
and external examination, (including dilation where professionally indicated,) refraction, binocular
function testing, tonometry, neurological integrity, biomicroscopy, keratometry, diagnosis and
treatment plan, and when authorized by state law and covered by a Plan, medical eye care, diagnosis,
treatment and eye care management services, and when applicable, ordering and dispensing plan
eyeglasses from a DAVIS laboratory.
.5 “Generally Accepted Standards of Medical Practice” means standards that are
based upon: credible scientific evidence published in peer-reviewed medical literature and generally
recognized by the relevant medical community; physician and health care provider specialty society
recommendations; the views of physicians and health care providers practicing in relevant clinical
areas and any other relevant factor as determined by statute(s) and/or regulation(s).
.6 “Managed Care Organization” (hereinafter “MCO”) means an entity that has or
is seeking to qualify for a comprehensive risk contract and that is: (1) a Federally qualified HMO
that meets the advance directives requirements of 42 CFR §489.100-104; or (2) any public or private
entity that meets the advance directives requirements and is determined to also meet the following
conditions: a) makes the services it provides to its enrollees as accessible (in terms of timeliness,
amount, duration, and scope) as those services are accessible to other recipients within the area
served by the entity, and b) meets the solvency standards of 42 CFR §438.116.
.7 “Medicaid” means the joint Federal and State program providing medical
assistance to low income persons pursuant to 42 U.S.C. §1369 et seq.
.8 “Medical Assistance Program” (hereinafter “MAP”) means the joint Federal and
State program, administered by the State and the Centers for Medicare and Medicaid Services (and
its successors or assigns), which provides medical assistance to low income persons pursuant to Title
42 of the United States Code, Chapter 7 of the Social Security Act, Subchapter XIX Grants to States
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2
for Medical Assistance Programs, Section 1396 et seq, as amended from time to time, or any
successor program(s) thereto regardless of the name(s) thereof.
.9 “Medical Necessity” / “Medically Necessary Services.” With respect to the
Medicaid and/or Medical Assistance Programs (MAP), “Medical Necessity” or “Medically
Necessary Services” are those services or supplies necessary to prevent, diagnose, correct, prevent
the worsening of, alleviate, ameliorate, or cure a physical or mental illness or condition; to maintain
health; to prevent the onset of an illness, condition, or disability; to prevent or treat a condition that
endangers life or causes suffering or pain or results in illness or infirmity; to prevent the
deterioration of a condition; to promote the development or maintenance of maximal functioning
capacity in performing daily activities, taking into account both the functional capacity of the
individual and those functional capacities that are appropriate for individuals of the same age; to
prevent or treat a condition that threatens to cause or aggravate a handicap or cause physical
deformity or malfunction, and there is no other equally effective, more conservative or substantially
less costly course of treatment available or suitable for the enrollee. The services provided, as well
as the type of provider and setting, must be reflective of the level of services that can be safely
provided, must be consistent with the diagnosis of the condition and appropriate to the specific
medical needs of the enrollee and not solely for the convenience of the enrollee or provider of
service and in accordance with standards of good medical practice and generally recognized by the
medical scientific community as effective. A course of treatment may include mere observation or
where appropriate no treatment at all. Experimental services or services generally regarded by the
medical profession as unacceptable treatment are not Medically Necessary Services for purposes of
this Agreement.
Medically Necessary Services provided must be based on peer-reviewed publications, expert
pediatric, psychiatric, and medical opinion, and medical/pediatric community acceptance. In the
case of pediatric Members/enrollees, the definition herein shall apply with the additional criteria that
the services, including those found to be needed by a pediatric Member as a result of a
comprehensive screening visit or an inter-periodic encounter, whether or not they are ordinarily
Covered Services for all other Medicaid Members are appropriate for the age and health status of the
individual, and the service will aid the overall physical and mental growth and development of the
individual, and the service will assist in achieving or maintaining functional capacity.
.10 “Medical Necessity” / “Medically Necessary” / “Medically Appropriate.”
With respect to the Medicare and/or Medicare Advantage Program, in order for services provided to
be deemed Medically Necessary or Medically Appropriate, Covered Services must: (1) be
recommended by a PROVIDER who is treating the Member and practicing within the scope of
her/his license and (2) satisfy each and every one of the following criteria:
(a)
The Covered Service is required in order to diagnose or treat the Member’s medical
condition (the convenience of the Member, of the Member’s family or of the Participating
Provider is not a factor to be considered in this determination); and
(b)
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The Covered Service is safe and effective: (i.e. the Covered Service must)
(i) be appropriate within generally accepted standards of practice;
(ii) be efficacious, as demonstrated by scientifically supported evidence;
3
(iii) be consistent with the symptoms or diagnosis and treatment of the Member’s
medical condition; and
(iv) the reasonably anticipated benefits of the Covered Service must outweigh the
reasonably anticipated risks; and
(c)
The Covered Service is the least costly alternative course of diagnosis or treatment
that is adequate for the Member’s medical condition; factors to be considered include, but
are not limited, to whether the Covered Service can be safely provided for the same or lesser
cost in a medically appropriate alternative setting; and
(d)
The Covered Service, or the specific use thereof, for which coverage is requested is
not experimental or investigational. A service or the specific use of a service is
investigational or experimental if there is not adequate, empirically-based, objective, clinical
scientific evidence that it is safe and effective. This standard is not met by (i) a Participating
Provider’s subjective medical opinion as to the safety or efficacy of a service or specific use
or (ii) a reasonable medical or clinical hypothesis based on an extrapolation from use in
another setting or from use in diagnosing or treating a different condition. Use of a drug or
biological product that has not received FDA approval is experimental. Off-label use of a
drug or biological product that has received FDA approval is experimental unless such offlabel use is shown to be widespread and generally accepted in the medical community as an
effective treatment in the setting and condition for which coverage is requested.
.11 “Medically Appropriate/Medical Necessity.” With respect to programs other
than Medicare, Medicare Advantage and Medicaid, the term “Medically Appropriate” means or
describes a vision care service(s) or treatment(s) that a PROVIDER hereunder, exercising
PROVIDER’s prudent, clinical judgment would provide to a Member for the purpose of evaluating,
diagnosing or treating an illness, injury, disease, or its symptoms and that is in accordance with the
“Generally Accepted Standards of Medical Practice”; and is clinically appropriate in terms of type,
frequency, extent site and duration; and is considered effective for the Member’s illness, injury or
disease; and is not primarily for anyone’s convenience; and is not more costly than an alternative
service or sequence of services that are at least as likely to produce equivalent therapeutic and/or
diagnostic results as to the Member’s illness, injury, or disease.
.12 “Medicare” means the Federal program providing medical assistance to aged and
disabled persons pursuant to Title 42 of the United States Code, Chapter 7 of the Social Security
Act, Subchapter XVIII Health Insurance for Aged and Disabled, Section 1395 et seq, as amended
from time to time, or any successor program(s) thereto regardless of the name(s) thereof.
.13 “Medicare Advantage Member” or “Medicare Advantage Subscriber” means
an individual who is enrolled in and covered under a Medicare Advantage Program or any successor
program(s) thereto regardless of the name(s) thereof. Dually eligible Medicare Advantage
Subscribers are those individuals who are (i) eligible for Medicaid; and (ii) for whom the state is
responsible for paying Medicare Part A and B cost sharing.
.14 “Medicare Advantage Program” means a product established by Plan pursuant
to a contract with the CMS which complies with all applicable requirements of Part C of Title 42 of
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4
United States Code, Chapter 7 of the Social Security Act, Subchapter XVIII Health Insurance for
Aged and Disabled, Section 1395 et seq, as amended from time to time, and which is available to
individuals entitled to and enrolled in Medicare or any successor program(s) thereto regardless of the
name(s) thereof.
.15 “Member” or “Enrollee” means an individual and the eligible dependent(s) of
such an individual who is enrolled in or who has entered into contract with or on whose behalf a
contract has been entered into with Plan(s), and who is entitled to receive Covered Services.
.16 “Negative Balance” means receipt of Copayments, Coinsurances, Deductibles or
other compensation by PROVIDER or Participating Provider which are in excess of the amounts
that are due to PROVIDER or Participating Provider for Covered Services under this Agreement.
.17 “Network” means the arrangement of Participating Providers established to
service eligible Members and eligible dependents enrolled in or who have entered into contract with,
or on whose behalf a contract has been entered into with Plan(s).
.18 “Non-Covered Services” means those vision care services which are not
Covered Services under Plan Contract(s).
.19 “Overpayment” means an incorrect claim payment made to a PROVIDER or
Participating Provider via check or wire transfer due to one or more of the following reasons: (i) a
DAVIS processing error (ii) an incorrect or fraudulent claim submission by PROVIDER or
Participating Provider (iii) a retroactive claim adjustment due to a change, oversight or error in the
implementation of a fee schedule.
.20 “Participating Provider” means a licensed health facility which has entered
into, or a licensed health professional who has entered into an agreement with DAVIS to provide
Medically Appropriate Covered Services to Members pursuant to the Plan Contract(s) between
DAVIS and Plan(s) and those employed and/or affiliated, independent, or subcontracted
optometrists or ophthalmologists who have entered into agreements with PROVIDER, who have
been identified to DAVIS and have satisfied Network participation criteria, and who will provide
Medically Appropriate Covered Services to Members pursuant to the Plan Contract(s) between
DAVIS and Plan(s). All obligations, terms, and conditions of this Agreement that are applicable to
PROVIDER shall similarly be applicable to and binding upon Participating Provider(s) as defined
herein.
.21 “Plan(s)” means a health maintenance organization, corporation, trust fund,
municipality, or other purchaser of vision care services that has entered into a Plan Contract with
DAVIS.
.22 “Plan Contract(s)” means the agreements between DAVIS and Plans to provide
for or to arrange for the provision of vision care services to individuals enrolled as Members of such
Plans.
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5
.23 “Provider Manual” means the DAVIS Vision Care Plan Provider Manual, as
amended from time to time by DAVIS.
.24 “State” means the State in which PROVIDER’s practice is located or the State
in which the PROVIDER renders services to a Member.
.25 “United States Code of Federal Regulations” (hereinafter “CFR”) means the
codification of the general and permanent rules and regulations published in the Federal Register by
the executive department and agencies of the federal government.
.26 “United States Department of Health and Human Services” (hereinafter
“DHHS”) means the executive department of the federal government which provides oversight to
the Centers for Medicare and Medicaid Services (CMS).
.27 “Urgently Needed Services” means Covered Services that are not emergency
services as defined in 42 CFR §422.113 provided when a Member is temporarily absent from the
Medicare Advantage Program Plan’s service area (or if applicable, continuation area) or, under
unusual and extraordinary circumstances, Covered Services provided when the Member is in the
service or continuation area but the Network is temporarily unavailable or inaccessible and when the
Covered Services are Medically Necessary and immediately required as a result of an unforeseen
illness, injury, or condition; and it was not reasonable, given the circumstances, to obtain the
Covered Services through the Medicare Advantage Plan Network. “Stabilized Condition” means a
condition whereby the physician treating the Member must decide when the Member may be
considered stabilized for transfer or discharge, and that decision is binding on the Plan.
III
SERVICES TO BE PERFORMED BY THE PROVIDER
.1 Frame Collection. As a bailment, and if applicable, PROVIDER shall maintain
the selection of Plan approved frames in accordance with the Provider Manual and as set forth
herein:
(a) PROVIDER agrees the frame collection will be shown to all Members receiving
eyeglasses under the Plan.
(b) PROVIDER agrees the frame collection shall be openly displayed in an area
accessible to all Members.
(c) PROVIDER shall maintain the frame collection in the exact condition in which
it was delivered less any normal deterioration.
(d) PROVIDER shall not permanently remove any frames from the display.
PROVIDER shall not remove any advertising materials from the display.
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6
(e) The cost of the frame collection and display is assumed by DAVIS and remains
the property of DAVIS. DAVIS retains the right to take possession of the frame
collection when PROVIDER ceases to participate with the Plan and at any other
time upon reasonable notice. PROVIDER assumes full responsibility for the
cost of any missing frames and will be required to reimburse DAVIS for missing
and unaccounted for frames.
(f) At any time and upon reasonable notice DAVIS shall have the right to alter the
advertising materials displayed as well as any frame(s) contained in the
collection.
(g) Should the display and/or frame(s) contained in the collection be damaged due to
acts of God, acts of terrorism, war, riots, earthquake, floods, or fire, PROVIDER
shall assume the full cost of the display and/or the frame collection and will be
required to reimburse DAVIS its/their fair market value.
.2 Open Clinical Dialogue. Nothing contained herein shall be construed to limit,
prohibit or otherwise preclude PROVIDER from engaging in open clinical dialogue with any
Member(s) or any designated representative of a Member(s) regarding: (a) any Medically Necessary
or Medically Appropriate care, within the scope of PROVIDER’s practice, including but not limited
to, the discussion of all possible and/or applicable treatments, including information regarding the
nature of treatment, risks of treatment, alternative treatments or the availability of alternative
treatments or consultations and diagnostic test, and regardless of benefit coverage limitations under
the terms of the Plan(s)’ documents or medical policy determinations and whether such treatments
are Covered Services under the applicable DAVIS benefit program designs; or (b) the process
DAVIS uses on its own behalf or on behalf of Plan(s) to deny payment for a vision care service; or
(c) the decision by DAVIS on its own behalf or on behalf of Plan(s) to deny payment for a vision
care service.
In addition, DAVIS and PROVIDER are prohibited, throughout the Term(s) of this
Agreement, from instituting gag clauses for their employees, contractors, subcontractors, or agents
that would limit the ability of such person(s) to share information with Plan(s) and/or any regulatory
agencies regarding the Medical Assistance MCO Program(s) and the Medicare Program(s).
.3 Services. PROVIDER shall provide all Medically Appropriate Covered Services
to Members within the scope of his/her/its license, and shall manage, coordinate and monitor all
such care rendered to each such Member to ensure that it is cost-effective and Medically
Appropriate. PROVIDER agrees and acknowledges that Covered Services hereunder shall be
governed by and construed in accordance with all laws, regulations, and contractual obligations of
the MCO. Throughout the entire Term(s) of this Agreement, PROVIDER shall maintain, in good
working condition, all necessary diagnostic equipment in order to perform all Covered Services as
defined in this Agreement.
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7
(a) To the extent required by law, DAVIS and/or Plan(s) will provide coverage of
Urgently Needed Services to Members of a Medicare Advantage Program and where applicable,
DAVIS shall reimburse PROVIDER for Urgently Needed Services rendered to Member(s) in order
to attain Stabilized Condition and in accordance with applicable laws, administrative requirements,
CMS regulations (42 CFR §422.113) and without regard to prior authorization for such services.
PROVIDER also agrees to notify DAVIS of Urgently Needed Services and any necessary followup services rendered to any Member(s).
.4 Scope of Practice. The Parties acknowledge and agree nothing contained in this
Agreement shall be construed as a gag clause limiting or prohibiting PROVIDER and/or
Participating Providers from acting within his/her/its lawful scope of practice, or from advising or
advocating on behalf of a current, prospective, or former patient or Member (or from advising a
person designated by a current, prospective, or former patient or Member who is acting on
patient/Member’s behalf) with regard to the following:
.4.1 The Member’s health status, medical care, or treatment options, including any
alternative treatment that may be self-administered;
.4.2
treatment options;
.4.3
Any information the Member needs in order to decide among all relevant
The risks, benefits, and consequences of treatment versus non-treatment;
.4.4
The Member’s right to participate in decisions regarding his or her health
care, including the right to refuse treatment and to express preferences about future treatment
decisions;
.4.5
Information or opinions regarding the terms, requirements or services of the
health care benefit plan as they relate to the medical needs of the patient; and
.4.6
The termination of PROVIDER’s agreement with the MCO or the fact that
the PROVIDER will otherwise no longer provide vision care services under the DAVIS Plan
Contract(s) with MCO.
.5 Treatment Records. PROVIDER shall (1) establish and maintain a treatment
record consistent in form and content with generally accepted standards and the requirements of
DAVIS and Plan(s); and (2) promptly provide DAVIS and Plan(s) with copies of treatment records
when requested; and (3) keep treatment records confidential. Treatment records shall be kept
confidential, but DAVIS and/or Plans shall have a mutual right to a Member’s treatment records, as
well as timely and appropriate communication of Member information, so that both the PROVIDER
and Plans may perform their respective duties efficiently and effectively for the benefit of the
Member.
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IV
COMPENSATION
.1 Billing. For all Covered Services rendered by PROVIDER to a Member
hereunder, PROVIDER shall, within sixty (60) days following the provision of Covered Services,
submit to DAVIS a Clean Claim which, may be written, electronic or verbal. shall be approved as to
form and content by DAVIS, and if applicable shall be the standard claim form mandated by the
State in which Covered Services were rendered. Failure of PROVIDER to submit said invoice
within sixty (60) days of service delivery will, at DAVIS’ option, result in nonpayment by DAVIS
to PROVIDER for the Covered Services rendered.
.2 Compensation. DAVIS shall pay PROVIDER the compensation amounts that
are communicated from time to time by DAVIS to PROVIDER. Such compensation amounts are
hereby incorporated by reference. Such compensation amounts are and shall be deemed to be full
compensation for the Covered Services provided by PROVIDER to Members under applicable
Plan(s) pursuant to this Agreement.
(a) In accordance with 42 CFR §422.504(g)(1)(iii), and to the extent applicable,
PROVIDER agrees that dually eligible Subscribers of Medicare Advantage plans shall not be held
liable for Medicare Parts A and B cost-sharing when the appropriate State Medicaid agency is liable
for the cost-sharing. PROVIDER further agrees that upon receiving payment from DAVIS for a
Medicare Advantage Subscriber, PROVIDER will either: (i) Accept the Medicare Advantage
payment as payment in full; or (ii) Bill the appropriate State source.
.3 Copayments, Coinsurance, Deductibles and Discounts. PROVIDER shall bill
and collect all Copayments, Coinsurances and Deductibles from Member(s), which are specifically
permitted and/or applicable to Member(s)’ benefit plan. PROVIDER shall bill and collect all
charges from a Member for those Non-Covered Services provided to a Member. PROVIDER may
only bill the Member when DAVIS has denied confirmation of eligibility for the service(s) and
when the following conditions are met:
(a) The Member has been notified by the PROVIDER of the financial liability in
advance of the service delivery;
(b) The notification by the PROVIDER is in writing, specific to the service being
rendered, and clearly states that the Member is financially responsible for the specific service. A
general patient liability statement which is signed by all patients is not sufficient for this purpose;
(c) The notification is dated and signed by the Member; and
(d) To the extent permitted by law, PROVIDER shall provide to Members either a
courtesy discount of twenty percent (20%) off of PROVIDER’s usual and customary fees for the
purchase of materials not covered by a Plan(s), and/or a discount of ten percent (10%) off of
PROVIDER’s usual and customary fees for disposable contact lenses.
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9
.4 Financial Incentives. DAVIS shall not provide PROVIDER with any financial
incentive to withhold Covered Services, which are Medically Appropriate. Further, the Parties
hereto agree to comply with and to be bound by, to the same extent as if the sections were restated in
their entirety herein, the provisions of 42 CFR §417.479 and 42 CFR §434.70, as amended by the
final rule effective January 1, 1997, and as promulgated by the CMS (formerly the Health Care
Financing Administration, DHHS). In part, these sections govern physician incentive plans operated
by federally qualified health maintenance organizations and competitive medical plans contracting
with the Medicare program, and certain health maintenance organizations and health insuring
organizations contracting with the Medicaid program. As applicable and pursuant to 42 CFR
§417.479 and 42 CFR §434.70, no specific payment will be made directly or indirectly, under Plans
hereunder to a physician or physician group, as an inducement to reduce or limit medically
necessary services furnished to a Member.
.5 Member Billing/Hold Harmless. Notwithstanding anything herein to the
contrary, PROVIDER agrees DAVIS’ payment hereunder constitutes payment in full and except as
otherwise provided for in a Member’s benefit program, PROVIDER shall look only to DAVIS for
compensation for Covered Services provided to Members and shall at no time seek compensation,
remuneration or reimbursement from Members, persons acting on Member(s)’ behalf, from the
MCO, the Plan, or the MAP for Covered Services even if DAVIS for any reason, including
insolvency or breach of this Agreement, fails to pay PROVIDER. No surcharge to any Member
shall be permitted. A surcharge shall, for purposes of this Agreement, be deemed to include any
additional fee not provided for in the Member’s benefit program. This hold harmless provision
supersedes any oral or written agreement to the contrary, either now existing or hereinafter entered
into between Member(s) or person acting on Member(s)’ behalf and PROVIDER, which relate to
liability for payment; shall survive termination of this Agreement regardless of the reason for
termination, shall be construed to be for the benefit of the Member(s) and shall not be changed
without the approval of appropriate regulatory authorities.
.6 Payment of Compensation. Payment shall be made to PROVIDER within thirty
(30) days of receipt of a Clean Claim by DAVIS or in accordance with the applicable state’s
prompt pay statute, whichever is most restrictive. Notwithstanding anything herein to the
contrary, PROVIDER shall bill DAVIS for all Covered Services rendered to a Member less any
Copayment, Coinsurances, and Deductibles collected or to be collected from the Member. If
PROVIDER is indebted to DAVIS for any reason, including, but not limited to, Overpayments,
Negative Balances or payments due for materials and supplies, DAVIS may offset such indebtedness
against any compensation due to PROVIDER pursuant to this Agreement.
(a) PROVIDER acknowledges and agrees no specific payment made by DAVIS or
Plan(s) for services provided under this Agreement is an inducement to reduce or to limit services or
products PROVIDER determines are Medically Necessary or Medically Appropriate within the
scope of PROVIDER’s practice and in accordance with applicable laws and ethical standards.
.7 Plan Hold Harmless Provisions. PROVIDER agrees PROVIDER shall look
only to DAVIS for compensation for Covered Services as set forth above and shall hold harmless
each Plan, the federal government, and the CMS from any obligation to compensate PROVIDER
for Covered Services.
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.8 Negative Balance. When a Negative Balance occurs, DAVIS has the right to
offset future compensation owed to PROVIDER or Participating Provider with the amount owed to
DAVIS and the right to bill PROVIDER or Participating Provider for such Negative Balance(s).
DAVIS will automatically, when possible, apply the Negative Balance to other outstanding payables
on PROVIDER’s account. In some instances it may be necessary for DAVIS to send an invoice to
PROVIDER for outstanding Negative Balance(s). The PROVIDER is responsible to remit
payment to DAVIS upon receipt of invoice. DAVIS retains the right to seek assistance from various
collection agencies and/or to suspend or permanently terminate PROVIDER from further
participation in DAVIS’ network in accordance with the suspension and termination provisions set
forth in this Agreement. A Negative Balance shall not mean an Overpayment as defined herein.
.9 Overpayment Recovery. At DAVIS’ sole discretion, DAVIS may bill
PROVIDER or Participating Provider for an Overpayment. PROVIDER shall be responsible to
remit payment on such an Overpayment invoice within forty-five (45) days from receipt of invoice.
Should DAVIS not receive payment within the aforementioned timeframe, DAVIS will, when
legally permissible, automatically apply the Overpayment to other outstanding payables on
PROVIDER’s account. DAVIS retains the right to seek assistance from various collection agencies
and/or to suspend or permanently terminate PROVIDER from further participation in DAVIS’
network in accordance with the suspension and termination provisions set forth in this Agreement.
Notwithstanding the foregoing, should this provision conflict with any applicable rules and
regulations, said rules and regulations shall govern. Notwithstanding the foregoing, DAVIS’
Overpayment recovery efforts shall comply with any legislative or statutory timeframe(s) specified
within the jurisdiction where services were provided.
V
OBLIGATIONS OF PROVIDER
.1 Access to Records. To the extent applicable and necessary for DAVIS and/or
Plan(s) to meet their respective data reporting and submission obligations to CMS, or other
appropriate governmental agency; PROVIDER shall provide to DAVIS and/or Plan(s) all data and
information in PROVIDER’s possession. Such information shall include, but shall not be limited to
the following:
.1.1
.1.2
.1.3
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any data necessary to characterize the context and purposes of each
encounter with a Member, including without limitation, appropriate
diagnosis codes applicable to a Member; and
any information necessary for Plan(s) to administer and evaluate
program(s); and
as requested by DAVIS, any information necessary (a) to show
establishment and facilitation of a process for current and prospective
Medicare Advantage Members to exercise choice in obtaining
Covered Services; (b) to report disenrollment rates of Medicare
Advantage Members enrolled in Plan(s) for the previous two (2)
years; (c) to report Medicare Advantage Member satisfaction; and (d)
11
.1.4
.1.5
.1.6
1.7
to report health outcomes; and
any information and data necessary for DAVIS and/or Plan(s) to
meet the physician incentive disclosure obligations under Medicare
Laws and CMS instructions and policies under 42 CFR §422.210;
and
any data necessary for DAVIS and/or Plan(s) to meet their respective
reporting obligations under 42 C.F.R. §§ 422.516 and 422.310, and
all other sections of 42 CFR. §422 relevant to reporting obligations;
and
PROVIDER shall certify (based upon best knowledge, information
and belief) the accuracy, completeness and truthfulness of
PROVIDER-generated encounter data that DAVIS and/or Plan(s)
are obligated to submit to CMS; and
PROVIDER and Participating Provider(s) shall hold harmless and
indemnify DAVIS and/or Plan(s) for any fines or penalties they may
incur due to PROVIDER’s submission or the submission by
Participating Provider(s) of inaccurate or incomplete books and
records.
.2 Coordination Of Benefits. PROVIDER shall cooperate with DAVIS with
respect to Coordination of Benefits (COB) and will bill and collect from other payer(s) such charges
for which the other payer(s) is responsible. PROVIDER shall report to DAVIS all payments and
collections received and attach all Explanations of Benefits (EOBs) in accordance with this
paragraph when billing is submitted to DAVIS for payment.
.3 Compliance with DAVIS and Plan Rules. PROVIDER agrees to be bound by
all of the provisions of the rules and regulations of DAVIS including, without limitation, those set
forth in the Provider Manual. PROVIDER recognizes that from time to time DAVIS may amend
such provisions and that such amended provisions shall be similarly binding on PROVIDER.
DAVIS shall maintain the Provider Manual to comply with applicable laws and regulations.
However, in instances when DAVIS’ rules are not in compliance, applicable State laws and
regulations shall take precedence and govern. PROVIDER agrees to cooperate with any
administrative procedures adopted by DAVIS regarding the performance of Covered Services
pursuant to this Agreement.
(a) To the extent that a requirement of the Medicare, Medicare Advantage, or
Medicaid Program is found in a policy, manual, or other procedural guide of DAVIS, Plan(s),
DHHS or other government agency, and is not otherwise specified in this Agreement, PROVIDER
will comply and agrees to require its employees, agents, subcontractors and independent contractors
to comply with such policies, manuals, and procedures with regard to the provision of Covered
Services to Members of such Programs.
(b) In the provision of Covered Services to Members, PROVIDER agrees to
comply, and agrees to require its employees, agents, subcontractors and independent contractors to
comply with all applicable laws and administrative requirements, including but not limited to:
Medicare, Medicare Advantage (and any successor program thereto), Medicaid and MAP laws and
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12
regulations, CMS instructions and policies; agrees to audits and inspections by the CMS and/or its
designees and shall cooperate, assist, and provide information as requested; and agrees to comply
with DAVIS’ and Plan(s)’ policies regarding credentialing, re-credentialing, utilization review,
quality improvement, performance improvement, medical management, external quality reviews,
peer review, complaint, grievance resolution and appeals processes, comparative performance
analysis, and enforcement and monitoring by appropriate government agencies, and activities
necessary for the external accreditation of DAVIS and/or Plan(s) by the National Committee for
Quality Assurance or any other similar organization selected by DAVIS and/or Plan(s), Further,
PROVIDER acknowledges and agrees DAVIS is accountable and responsible to the State MAP
which shall, on an ongoing basis, monitor performance under this Agreement to ensure the
performance of the Parties is consistent with the Plan Contract between DAVIS and the MCO and
consistent with the contract between the State MAP and the MCO.
(c) In relation to the provision of Covered Services to Medicare and Medicare
Advantage Members and Plan(s) hereunder, PROVIDER and PROVIDER’s employees, agents,
subcontractors, and independent contractors, must meet all applicable Medicare Advantage
credentialing and re-credentialing requirements and processes and agree to all of the following:
DAVIS and Plan(s) are ultimately accountable and responsible to the CMS for services delivered
and performed by PROVIDER hereunder; all services delivered and performed by PROVIDER
hereunder must be delivered and performed in accordance with the requirements of Plan agreements
with the CMS and with Medicare laws and regulations; such services shall, on an ongoing basis, be
monitored by the Plan(s) and/or the CMS and their respective delegates; the Plan(s) and/or the CMS
retain the right to approve, suspend, or to terminate any PROVIDER from such Plan(s); the
Managed Care Organization (MCO) is accountable to the CMS for any functions and responsibilities
described in the Medicare regulations pursuant to 42 CFR §422.504; and PROVIDER is required to
comply with the MCO’s policies and procedures.
.4 Compliance with Laws and Ethical Standards. During the Term of this
Agreement, PROVIDER and DAVIS shall at all times comply with all applicable federal, state or
municipal statutes or ordinances, including but not limited to, all applicable rules and regulations, all
applicable federal and state tax laws, all applicable federal and state criminal laws as well as the
customary ethical standards of the appropriate professional society from which PROVIDER seeks
advice and guidance or to which PROVIDER is subject to licensing and control. PROVIDER shall
comply with all applicable laws and administrative requirements, including but not limited to,
Medicaid laws and regulations, Medicare laws, CMS instructions and policies, DAVIS’ and Plan(s)’
credentialing policies, processes, utilization review, quality improvement, medical management,
peer review, complaint and grievance resolution programs, systems and procedures. If at any time
during the Term of this Agreement PROVIDER’s license to operate or to practice his/her/its
profession is suspended, conditioned or revoked, PROVIDER shall immediately notify DAVIS and
without regard to a final adjudication or disposition of such suspension, condition or revocation, this
Agreement shall immediately terminate, become null and void, and be of no further force or effect,
except as provided herein. PROVIDER agrees to cooperate with DAVIS in order that DAVIS may
comply with any requirements imposed by state and federal law, as amended, and all regulations
issued pursuant thereto.
.5 Confidentiality of Member Information. PROVIDER agrees to abide by all
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13
Federal and State laws regarding confidentiality, including unauthorized uses of or disclosures of
patient information and personal health information.
(a) PROVIDER shall safeguard all information about Members according to
applicable State and federal laws and regulations. All material and information, in particular
information relating to Members or potential Members which is provided due to, or is obtained by or
through PROVIDER’s performance under this Agreement, whether verbal, written, tape, or
otherwise, shall be reported as confidential information to the extent confidential treatment is
provided under State and federal laws. PROVIDER shall not use any information so obtained in
any manner except as necessary for the proper discharge of PROVIDER’s obligations and the
securement of PROVIDER’s rights under this Agreement.
(b) Neither DAVIS nor PROVIDER shall share confidential information with any
Member(s)’ employer, absent the Member(s)’ written consent for such disclosure. PROVIDER
agrees to comply with the requirements of the Health Insurance Portability and Accountability Act
(“HIPAA”) relating to the exchange and to the storage of Protected Health Information (“PHI”), as
defined by Title 45 of the CFR, Part 160.103 in whatever form or medium PROVIDER may obtain
and maintain such PHI. PROVIDER shall cooperate with DAVIS in its efforts to ensure
compliance with the privacy regulations promulgated under HIPAA and other related privacy laws.
(c) PROVIDER and DAVIS acknowledge and agree the activities conducted to
perform the obligations undertaken in this Agreement are or may be subject to HIPAA as well as the
regulations promulgated to implement HIPAA. PROVIDER and DAVIS agree to conduct their
respective activities, as described herein, in accordance with the applicable provisions of HIPAA
and such implementing regulations. PROVIDER and DAVIS further agree to the extent HIPAA or
such implementing regulations require amendments(s) hereto, PROVIDER and DAVIS shall
conduct good faith negotiations to amend this Agreement.
.6 Consent to Release Information. Upon request by DAVIS PROVIDER shall
provide DAVIS with authorizations, consents or releases, in connection with any inquiry by DAVIS
of any hospital, educational institution, governmental or private agency or association (including
without limitation the National Practitioner Data Bank) or any other entity or individual relative to
PROVIDER’s professional qualifications, PROVIDER’s mental or physical fitness, or the quality
of care rendered by PROVIDER.
.7 Cooperation with Plan Medical Directors. PROVIDER understands
contracting Plans will place certain obligations upon DAVIS regarding the quality of care received
by Members and in certain instances Plans will have the right to oversee and review the quality of
care administered to Members. PROVIDER agrees to cooperate with Plan(s)’ medical directors in
the medical directors' review of the quality of care administered to Members.
.8 Credentialing, Licensing and Performance. PROVIDER agrees to comply
with all aspects of DAVIS’ credentialing and re-credentialing policies and procedures and the
credentialing and re-credentialing policies and procedures of any Plan contracting with DAVIS.
PROVIDER agrees he/she/it shall be duly licensed and certified under applicable State and federal
statutes and regulations to provide the vision care services that are the subject of this Agreement,
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14
shall hold Diagnostic Pharmaceutical Authorization (DPA) certification to provide Dilated Fundus
Examinations (DFE), and shall participate in such programs of continuing education required by
State regulatory and licensing authorities. Further, PROVIDER shall assist and facilitate in the
collection of applicable information and documentation to perform credentialing and recredentialing of PROVIDER as required by DAVIS, Plan(s) or the CMS. Such documentation shall
include, but shall not be limited to proof of: National Provider Identifier Number, licensure,
certification, provider application, professional liability insurance coverage, undergraduate and
graduate education and professional background. PROVIDER agrees DAVIS shall have the right
to source verify the accuracy of all information provided, and at DAVIS’ sole option, the right to
deny any professional participation in the Network or the right to remove from Network
participation any professional for whom inadequate, inaccurate, or otherwise unacceptable
information is provided. PROVIDER agrees at all times, and to the extent of his/her/its knowledge,
PROVIDER shall immediately notify DAVIS, in writing, in the event PROVIDER suffers a
suspension or a termination of license or professional liability insurance coverage. PROVIDER
shall; (a) devote the time, attention and energy necessary for the competent and effective
performance of duties hereunder to Member(s), (b) ensure vision care services provided under this
Agreement are of a quality that is consistent with accepted professional practices, and (c) abide by
the standards established by DAVIS including, but not limited to, standards relating to the utilization
and quality of vision care services.
.9 Fraud/Abuse and Office Visits. Upon the request of the CMS, the DHHS, the
MAP, or any appropriate external review organization or regulatory agency (“Oversight Entities”)
PROVIDER shall make available for audit, all administrative, financial, medical, and all other
records that relate to the delivery of items or services under this Agreement. PROVIDER shall
provide all such access to the aforementioned records in the form and format requested and at no
cost to DAVIS and/or to the requesting Oversight Entity. Further, the PROVIDER shall cooperate
with and allow such Oversight Entities access to these records during normal business hours, except
under special circumstances when PROVIDER shall permit after hour access. PROVIDER shall
cooperate with all office visits made by DAVIS or any Oversight Entity.
.10 Hours and Availability of Services. Pursuant to and in accordance with 42
CFR §438.206(c)(1), PROVIDER and Participating Provider(s) agree to be available to provide
Covered Services for Medically Appropriate care, taking into account the urgency of the need for
services and when necessary and appropriate, to provide Covered Services for Medically
Appropriate emergency care. PROVIDER and Participating Provider(s) shall ensure that Members
will have access to either an answering service, a pager number, and/or an answering machine,
twenty-four (24) hours per day, seven (7) days per week, in order that Members may ascertain
PROVIDER’s office hours, have an opportunity to leave a message for the PROVIDER and/or
Participating Provider(s) regarding a non-emergent concern and to receive pre-recorded instructions
with respect to the handling of an emergency.
(a) PROVIDER agrees PROVIDER is subject to regular monitoring of his/her/its
compliance with the appointment wait time (timely access) standards of 42 CFR §438.206(c)(1). As
such PROVIDER agrees and understands that corrective action shall be implemented should
PROVIDER and/or Participating Provider(s) fail to comply with timely access standards and that
Plan(s) have the right to approve DAVIS’ scheduling and administration standards.
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15
(b) PROVIDER agrees to provide DAVIS with thirty (30) calendar days notice if
PROVIDER and/or Participating Provider shall (a) be unavailable to provide Covered Services to
Members, (b) move his/her/its office location, (c) change his/her/its place of employment (d) change
his/her/its employer, or (e) reduce capacity at an office location. The thirty (30) calendar day notice
shall, at a minimum, include the effective date of the change, the new tax identification number and
a copy of the W-9 as applicable, the name of the new practice, the name of the contact person, the
address, telephone and fax numbers and other such information as may materially differ from the
most recently completed credentialing application submitted by PROVIDER and/or Participating
Provider to DAVIS. Under no circumstance shall the provision of Covered Services to Members by
PROVIDER be denied, delayed, reduced or hindered because of the financial or contractual
relationship between PROVIDER and DAVIS.
.11 Indemnification. PROVIDER shall indemnify and hold harmless DAVIS, the
Plan(s) and the State and their respective agents, officers and employees against all injuries, deaths,
losses, damages, claims, suits, liabilities, judgments, costs and expenses which, in any manner may
accrue against DAVIS, the Plan(s) or the State, and their respective agents, officers, or employees
through PROVIDER’s intentional conduct, negligent acts or omissions, or the intentional conduct,
negligent acts or omissions of PROVIDER’s employees, agents, affiliates, subcontractors, or
independent contractors.
(a) To the extent applicable, PROVIDER agrees to indemnify and hold harmless the
State and the CMS from all losses, damages, expenses, claims, demands, suits, and actions brought
by any party against the State or the CMS as a result of a failure of PROVIDER or PROVIDER’s
agents, employees, subcontractors or independent contractors to comply with the NonDiscrimination provisions contained herein.
.12 Malpractice Insurance. PROVIDER shall, at PROVIDER’s sole cost and
expense and throughout the entire Term of this Agreement, maintain a policy (or policies) of
professional malpractice liability insurance in a minimum amount of One Million Dollars
($1,000,000.00) per occurrence and Three Million Dollars ($3,000,000.00) in the annual aggregate,
to cover any loss, liability or damage alleged to have been committed by PROVIDER, or
PROVIDER’s agents, servants, employees, affiliates, independent contractors and/or
subcontractors, and PROVIDER shall provide evidence of such insurance to DAVIS if so
requested. In addition, and in the event the foregoing policy (or policies) is a “claims made” policy,
PROVIDER shall, following the effective termination date of the foregoing policy, maintain “tail
coverage” with the same liability limits. The foregoing policies shall not limit PROVIDER’s ability
to indemnify the State or enrollees of a Medical Assistance Program.
(a) PROVIDER shall cause his/her/its employed, affiliated, independent or
subcontracted Participating Provider(s) to substantially comply with Article V.12 above, and
throughout the Term of this Agreement and upon DAVIS’ request, PROVIDER shall provide
evidence of such compliance to DAVIS.
.13 Nondiscrimination. Nothing contained herein shall preclude PROVIDER from
rendering care to patients who are not covered under one or more of the Plans; provided that such
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16
patients shall not receive treatment at preferential times or in any other manner preferential to
Member(s) covered under one or more of the Plans or in conflict with the terms of this Agreement.
PROVIDER shall comply with the “General Prohibitions Against Discrimination,” 28 CFR §35.130
and similar regulations or guidelines that apply to the agencies with which Plan(s) contract. In
accordance with Title VI of the Civil rights Act of 1964 (45 CFR 84) and The Age Discrimination
Act of 1975 (45 CFR 91) and The Rehabilitation Act of 1973, and the regulations implementing the
Americans with Disabilities Act (“ADA”), 28 CFR §35.101 et seq., PROVIDER agrees not to
differentiate or discriminate as to the quality of service(s) delivered to Members because of a
Member’s race, gender, marital status, veteran status, age, religion, color, creed, sexual orientation,
national origin, disability, place of residence, economic status, health status (including but not
limited to medical condition), medical history, genetic information, need for services, receipt of
health care, evidence of insurability (including conditions arising out of acts of domestic violence),
claims experience, or method of payment; agrees to adhere to 42 CFR §§422.110 and 422.502(h) as
applicable and in conformity with all laws applicable to the receipt of Federal funds including any
applicable portions of the U.S. Department of Health and Human Services, revised Guidance to
Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin
Discrimination Affecting Limited English Proficient Persons (“Revised DHHS LEP Guidance”); and
PROVIDER agrees to promote, observe and protect the rights of Members. Pursuant to and in
accordance with 42 CFR §438.206(c)(2), PROVIDER and Participating Provider(s) agree Covered
Services hereunder shall be provided in a culturally competent manner to all Members, including
those with limited English proficiency and diverse cultural and ethnic backgrounds, and
PROVIDER shall maintain written procedures as to interpretation and translation services for
Members requiring such services. During the Term of this Agreement, PROVIDER shall not
discriminate against any employee or any applicant for employment with respect to any employee’s
or applicant’s hire, tenure, terms, conditions, or privileges of employment due to such individual’s
race, color, religion, gender, disability, marital status or national origin.
.14 Notice of Non-Compliance and Malpractice Actions. PROVIDER shall
notify DAVIS immediately, in writing, should PROVIDER be in violation of any portion of this
Section V. Additionally, PROVIDER shall advise DAVIS of each malpractice claim filed against
PROVIDER and each settlement or other disposition of a malpractice claim entered into by
PROVIDER within fifteen (15) days following said filing, settlement or other disposition.
.15 Participation Criteria. PROVIDER hereby warrants and represents that
PROVIDER, and all of PROVIDER’s employees, affiliates, subcontractors and/or independent
contractors who provide Covered Services under this Agreement, including without limitation health
care, utilization review, and/or administrative services currently meet, and throughout the Term of
this Agreement shall continue to meet any and all applicable conditions necessary to participate in
the Medicare/Medicare Advantage program, including general provisions relating to nondiscrimination, sexual harassment or fraud and abuse, as well as all applicable laws pertaining to the
receipt of federal funds; federal laws designed to prevent or ameliorate fraud, waste and abuse,
including applicable provisions of federal criminal law, the False Claims Act (31 U.S.C. §3729 et
seq.) and the anti-kickback statute (42 U.S.C. §1320a-7b(b)), 42 CFR §§422.504(h)(l),
423.505(h)(l), and the HIPAA administrative simplification rules at 45 CFR Parts 160, 162, and 164.
PROVIDER hereby warrants and represents PROVIDER and all of PROVIDER’s employees,
affiliates, subcontractors, and/or independent contractors are not excluded, sanctioned or barred from
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17
participation under a federal health care program as described in Sections 1128B(b) and 1128B(f) of
the Social Security Act, and all employees, affiliates, subcontractors, and/or independent contractors
of PROVIDER are able to provide a current National Provider Identifier number, as applicable.
(a) PROVIDER understands and agrees meeting the Participation Criteria is a
condition precedent to PROVIDER’s participation, and a condition precedent to the participation by
PROVIDER’s employees, affiliates, subcontractors, and/or independent contractor(s) hereunder
and, is an ongoing condition to the provision of Covered Services hereunder by both the
PROVIDER as well as a condition precedent to the reimbursement by DAVIS for such Covered
Services rendered by PROVIDER. Upon PROVIDER’s meeting all of the Participation Criteria
set forth in this Agreement PROVIDER shall participate as a Participating Provider for
Plan(s)/programs covered under this Agreement.
(b) PROVIDER may not employ, contract with, or subcontract with an individual,
or with an entity that employs, contracts with, or subcontracts with an individual, who is excluded
from participation in Medicare under Section 1128 or 1128A of the Social Security Act or from
participation in a federal health care program for the provision of any of the following: (a) health
care, (b) utilization review, (c) medical social work or (d) administrative services. PROVIDER
acknowledges and understands this Agreement shall automatically be terminated if PROVIDER,
any practitioner, or any person with an ownership or control interest in PROVIDER, is excluded
from participation in Medicare under Section 1128 or 1128A of the Social Security Act or from
participation in any other federal health care program. Any payments received by PROVIDER
hereunder on or after the date of such exclusion shall constitute overpayments.
.16 PROVIDER Directory. PROVIDER understands and agrees DAVIS and
Plan(s) reserve the right to use PROVIDER’s name, address, telephone number, type of practice,
and willingness to accept new patients for the purposes of printing and distributing provider
directories to Member(s). Such directories are intended for and may be inspected and used by
prospective patients and others.
.17 Record Requirements and Retention. PROVIDER shall maintain adequate,
accurate, and legible medical, financial and administrative records related to Covered Services
rendered by PROVIDER. Such records shall be written in English and in accordance with federal
and State law. PROVIDER shall have written policies and procedures for storing all records.
(a) Pursuant to 42 CFR §§422.504 and 423.505 and in accordance with CMS
regulations, PROVIDER and PROVIDER’s employees, affiliates, subcontractors and independent
contractors agree to safeguard and maintain, in an accurate and timely manner, contracts, books,
documents, papers, records and Member medical records pertaining to and pursuant to
PROVIDER’s performance of PROVIDER’s obligations under a Medicare or Medicare Advantage
program hereunder, and agrees to provide such information to DAVIS, contracting Plans, applicable
state and federal regulatory agencies, including but not limited to the DHHS, the Office of the
Comptroller General or their designees, for inspection, evaluation, and audit. PROVIDER agrees to
retain such books and records for a term of at least ten (10) years from the final date of the contract
period or from the date of completion of any audit, or for such longer period of time provided for in
42 CFR §§422.504, 423.505, or other applicable law, whichever is later. In the case of a minor
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Member, PROVIDER shall retain such information for a minimum of ten (10) years after the time
such minor attains the age of majority or ten (10) years from the final date of the contract period or
from the date of completion of an audit, or for such longer period of time provided for in 42 CFR
§§422.504, 423.505, or other applicable law, whichever is later. PROVIDER shall make available
premises, physical facilities, equipment, records and any relevant information the CMS may require
which pertains to Covered Services provided to Medicare Advantage Program Members.
PROVIDER and Participating Provider(s) shall cooperate with any such review or audit by
assisting in the identification and collection of any books, records, data, or clinical records, and shall
make appropriate practitioner(s), employees, and involved parties available for interviews, as
requested. Such records shall be truthful, reliable, accurate, complete, legible, and provided in the
specified form. PROVIDER and Participating Provider(s) shall hold harmless and indemnify
DAVIS and/or Plan(s) for any fines or penalties they may incur due to PROVIDER’s submission,
or the submission by Participating Provider(s) of inaccurate or incomplete books and records.
(b) All hard copy or electronic records, including but not limited to working papers
or information related to the preparation of reports, medical records, progress notes, charges,
journals, ledgers, and fiscal reports, which are originated or are prepared in connection with and
pursuant to PROVIDER’s performance of PROVIDER’s obligations under a Medicaid program
hereunder, will be retained and safeguarded by the PROVIDER and PROVIDER’s employees,
affiliates, subcontractors and independent contractors, in accordance with applicable sections of the
federal and State regulations. Records stored electronically must be produced at the PROVIDER’s
expense, upon request, in the format specified by State or federal authorities. All such records must
be maintained for a minimum of ten (10) years from the termination date of this Agreement or, in the
event that the PROVIDER has been notified that State or federal authorities have commenced an
audit or investigation of this Agreement, or of the provision of services by the PROVIDER, or by
PROVIDER’s subcontractor or independent contractor, all records must be maintained until such
time as the matter under audit or investigation has been resolved, whichever is later.
(c) PROVIDER’s obligations contained in Section V.17 herein shall survive
termination of this Agreement.
.18 Subcontractors. PROVIDER agrees that in no event shall PROVIDER or
Participating Provider(s) enter into subcontracts or lease arrangements with any person or entity
outside of the jurisdiction of the United States (“offshore subcontractor”) for the purpose of
rendering vision care services to Medicare/Medicare Advantage Members covered under this
Agreement or any addenda or attachment hereto without the prior, written approval of DAVIS, the
Medicare Advantage Plan and the CMS. Failure to obtain prior approval may result, at the
discretion of DAVIS or Plan, in the immediate termination of PROVIDER and/or Participating
Provider(s). PROVIDER agrees if PROVIDER enters into any permitted subcontracts or lease
arrangements to render any health/vision care services permitted under the terms of this Agreement,
PROVIDER’s subcontracts or lease arrangements shall include the following:
(a) an agreement by the subcontractor or leaseholder to comply with all of
PROVIDER’s obligations in this Agreement; and
(b) a prompt payment provision as negotiated by PROVIDER and the subcontractor
or leaseholder; and
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(c) a provision setting forth the terms of payment, any incentive arrangements, and
any additional payment arrangements; and
(d) a provision setting forth the term of the subcontract or lease (preferably a
minimum of one [1] year); and
(e) the dated signature of all parties to the subcontract.
.19 Training Regarding the Plan Contracts. PROVIDER agrees to train his/her/its
Participating Providers and staff at all duly credentialed PROVIDER offices regarding the fees and
benefit or plan designs for Plan Contracts.
.20 Verification of Eligibility. DAVIS shall make available to PROVIDER a
system for determining eligibility of Members seeking services under benefit programs hereunder.
PROVIDER agrees to comply with the eligibility system requirements and to obtain a valid,
confirmation of eligibility number prior to rendering services to any Member. To verify eligibility
of Member(s) PROVIDER shall call the appropriate toll-free (800/888) number supplied by
DAVIS, or access the DAVIS website (www.davisvision.com), or receive from Member(s) a valid
pre-certified voucher. In order for PROVIDER to receive reimbursement for services rendered to a
Member, services must be provided within the timeframe communicated to PROVIDER upon
receipt of a confirmation of eligibility number, or upon PROVIDER’s receipt of an extension of the
original confirmation of eligibility number. Neither DAVIS nor Plan(s) shall have any obligation to
reimburse PROVIDER for any services rendered without a valid confirmation of eligibility number.
However, if DAVIS provides erroneous eligibility information to PROVIDER, and if benefits under
the program(s) are provided to a Member, DAVIS shall reimburse PROVIDER for any benefits
provided to a Member.
VI
TERM OF THE AGREEMENT
.1 Term. This Agreement shall become effective on the Effective Date appearing on
the signature page herein, and shall thereafter be effective for an initial Term of twelve (12) months.
.2 Renewals. Unless this Agreement is terminated in accordance with the termination
provisions herein, this Agreement shall automatically renew for up to, but not more than, three (3)
successive twelve (12) month Terms on the same terms and conditions contained herein.
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VII
TERMINATION OF THE AGREEMENT
.1 Termination Without Cause. After the initial twelve (12) month Term has
ended, this Agreement may be terminated by either Party without cause, upon ninety (90) days prior,
written notice. If DAVIS elects to terminate this Agreement other than at the end of the initial Term
hereof, or for a reason other than those set forth in Sections VII.1 and VII.2 hereof, PROVIDER
may request a hearing before a panel appointed by DAVIS. Such hearing will be held within thirty
(30) days of receipt of PROVIDER’s request or within such time as is required by applicable law or
regulation.
.2 Termination With Cause. DAVIS may terminate this Agreement immediately
for cause or may suspend continued participation as set forth below. “Cause” shall mean:
(a) a suspension, revocation or conditioning of PROVIDER’s license to
operate or to practice his/her/its profession;
(b) a suspension, or a history of suspension, of PROVIDER from Medicare or
Medicaid;
(c) conduct by PROVIDER which endangers the health, safety or welfare of
Members;
(d) any other material breach of any obligation of PROVIDER under the
terms of this Agreement, to include but not be limited to fraud;
(e) a conviction of a felony;
(f) a loss or suspension of a Drug Enforcement Administration (DEA)
identification number;
(g) a voluntary surrender of PROVIDER’s license to practice in any state in
which the PROVIDER serves as a DAVIS Provider while an investigation into the PROVIDER’s
competency to practice is taking place by the state’s licensing authority;
(h) the bankruptcy of PROVIDER.
“Cause” for the purposes of suspension shall mean:
(a) a failure by PROVIDER to maintain malpractice insurance coverage as
provided in Section V.12 hereof;
(b) a failure by PROVIDER to comply with applicable laws, rules,
regulations, and ethical standards as provided in Section V.4 hereof;
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(c) a failure by PROVIDER to comply with DAVIS’ rules and regulations as
required in Section V.3 hereof;
(d) a failure by PROVIDER to comply with the utilization review and quality
management procedures described in Section IX.3 hereof;
(e) a violation by PROVIDER of the non-solicitation covenant set forth in
Section X.9 hereof;
Provided, however, that PROVIDER shall not be penalized nor shall this Agreement be terminated
or suspended because PROVIDER acts as an advocate for a Member in seeking appropriate
Covered Services, or files a complaint or an appeal.
.3 Termination Related to Medicare Advantage. At the sole discretion of the
CMS, Plan(s) and/or DAVIS, this Agreement may be immediately terminated, as it relates to
PROVIDER’s provision of Covered Services to Medicare Advantage Members hereunder for the
following reasons:
.3.1
The termination is for breach of contract, or there is a determination of
fraud; or
.3.2
In the opinion of DAVIS’ medical director or its equivalent, the health care
professional represents an imminent danger to an individual patient or the public health, safety or
welfare; or
.3.3 A decision by the CMS, Plan(s), and/or DAVIS that: (i) PROVIDER has not
performed satisfactorily, or (ii) PROVIDER’s reporting and disclosure obligations under this
Agreement are not fully met or timely met; or
.3.4
The failure of PROVIDER to comply with the equal access and nondiscrimination requirements set forth in this Agreement.
.4 Responsibility for Members at Termination. In the event that this Agreement is
terminated (other than for loss of licensure or failure to comply with legal requirements as provided
in Section V hereof), PROVIDER shall continue to provide Covered Services to a Member who is
receiving Covered Services from PROVIDER on the effective termination date of this Agreement
for a minimum transitional period of sixty (60) days from the date the Member is notified of the
termination or pending termination, or until the Covered Services being rendered to the Member by
PROVIDER are completed (consistent with existing medical ethical and/or legal requirements for
providing continuity of care to a Member), unless DAVIS or a Plan makes reasonable and Medically
Appropriate provision for the assumption of such Covered Services by another Participating
Provider. DAVIS shall compensate PROVIDER for those Covered Services provided to a Member
pursuant to this paragraph (prior to and following the effective termination date of this Agreement)
at the rates contemplated for Covered Services in this Agreement.
(a) In consultation with Plan(s), the Member and/or the PROVIDER may extend the
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22
transitional period if it is determined to be clinically appropriate, or in order to comply with the
requirements of applicable Plan documents and/or accrediting standards. PROVIDER shall
continue to provide Covered Services to such Member(s) and the Parties agree that all such Covered
Services rendered shall be subject to the terms and conditions contained in this Agreement
(including reimbursement rates) that are effective as of the date of termination.
(b) Should DAVIS and/or Plan(s) initiate termination of this Agreement,
PROVIDER acknowledges and agrees PROVIDER’s obligations as set forth in this Section VII
survive such termination.
.5 PROVIDER Rights Upon Termination. Except as otherwise required by law,
PROVIDER agrees, subject to the appeal process set forth in the Provider Manual, any DAVIS
decision to terminate this Agreement pursuant to this Section VII shall be final.
(a) PROVIDER acknowledges and understands Plan(s) have the authority to
determine whether a PROVIDER shall be suspended or terminated from participation in a particular
Plan without termination of this Agreement. However, Plan(s) shall not have the authority to
terminate PROVIDER for (a) maintaining a practice that includes a substantial number of patients
with expensive health conditions; (b) objecting to or refusing to provide a Covered Service on moral
or religious grounds; (c) advocating for Medically Appropriate care consistent with the degree of
learning and skill ordinarily possessed by a reputable health care provider practicing according to the
applicable standard of care; (d) filing a grievance on behalf of and with the written consent of a
Member or helping a Member to file a grievance; and (e) protesting a Plan decision, policy or
practice that PROVIDER reasonably believes interferes with the provision of Medically
Appropriate care.
.6 Return of Materials, Payments of Amounts Due and Settlement of Claims. If
applicable and upon reasonable notice, DAVIS may reclaim frame samples at any time during the
Term of this Agreement. Upon termination of this Agreement, PROVIDER shall return to DAVIS
any Plan or DAVIS materials including, but not limited to frame samples, displays, manuals and
contact lens materials, and shall pay DAVIS any monies due with respect to claims or for materials
and supplies. DAVIS may setoff any monies due from PROVIDER to DAVIS. PROVIDER
agrees to promptly supply to DAVIS all records necessary for the settlement of outstanding medical
claims.
.7 Provider Notification to Members upon Termination. Should PROVIDER
terminate this Agreement pursuant to Section VII.1 above, or should PROVIDER move office
location, or should a particular practitioner leave PROVIDER’s practice or otherwise become
unavailable to the Member(s) under this Agreement, PROVIDER agrees to notify effected
Member(s) a minimum of thirty (30) days prior to the effective date of such action or termination.
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23
VIII
DOCUMENTATION AND AMENDMENT
.1 Amendment. This Agreement may be amended by DAVIS with thirty (30) days
advance, written notice to PROVIDER. Notwithstanding the foregoing, this Agreement may also
be amended by written consent of the Parties hereto.
.2 Documentation. DAVIS shall provide PROVIDER with a copy of any
document(s) required by contracting Plan(s), which has been approved by DAVIS and requires
PROVIDER’s signature. If PROVIDER does not execute and return said document(s) within
fifteen (15) calendar days of document receipt, or if PROVIDER does not provide DAVIS with a
written notice of termination in accordance with the termination provision(s) contained herein,
DAVIS may execute said document(s) as agent of PROVIDER and said document(s) shall be
deemed to be executed by PROVIDER.
.3 Modification of Law, Rules, and Regulations. Notwithstanding anything herein
to the contrary, should any pertinent Federal or State law(s), regulation(s), rule(s), directive(s),
and/or policies be amended, repealed, or legislated, DAVIS shall reserve the right to amend this
Agreement without prior notice to or consent from PROVIDER. Such amended laws and
implementing regulations shall apply as of their respective effective dates and this Agreement shall
automatically amend to conform to such changes without necessitating an execution of written
amendments. Nonetheless, DAVIS shall employ its best efforts to notify PROVIDER of such
occurrences, where necessary, within a practicable timeframe.
.4 Upon Request of CMS. Upon request of the CMS, this Agreement and any
addenda may be amended to exclude any Medicare Advantage Program Plan or State-licensed entity
specified by the CMS. When such a request is made, a separate contract for any such excluded Plan
or entity will be deemed to be in place.
IX
UTILIZATION REVIEW, QUALITY
MANAGEMENT, QUALITY IMPROVEMENT AND GRIEVANCE PROCEDURES
.1 Access to Records. PROVIDER shall make all records related to PROVIDER’s
activities undertaken pursuant to the terms of this Agreement available for fiscal audit, medical
audit, medical review, utilization review and other periodic monitoring upon request of Oversight
Entities at no cost to the requesting entity.
(a) Upon termination of this Agreement for any reason, PROVIDER shall, in a
useable form, make available to any Oversight Entities, all records, whether dental/medical or
financial, related to PROVIDER’s activities undertaken pursuant to the terms of this Agreement at
no cost to the requesting entity.
.2 Consultation with Provider. DAVIS agrees to consult with PROVIDER
regarding DAVIS’ medical policies, quality improvement program and medical management
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24
programs and ensure that practice guidelines and utilization management guidelines:
(a) are based on reasonable medical evidence or a consensus of health care
professionals in the particular field;
(b) consider the needs of the enrolled population;
(c) are developed in consultation with Participating Providers who are physicians;
and are reviewed and updated periodically; and
(d) are communicated to Participating Providers of the Plan(s) and as appropriate to
the Members.
With respect to utilization management, Member education, coverage of health care
services, and other areas in which guidelines apply, DAVIS shall ensure decisions are consistent
with applicable guidelines.
.3 Establishment of UR/QM Programs. Utilization review and quality
management programs shall be established to review whether services rendered by PROVIDER
were Medically Appropriate and to determine the quality of Covered Services furnished by
PROVIDER to Members. Such programs will be established by DAVIS, in its sole and absolute
discretion, and will be in addition to any utilization review and quality management programs
required by a Plan. PROVIDER shall comply with and, subject to PROVIDER’s rights of appeal,
shall be bound by all such utilization review and quality management programs. If requested,
PROVIDER may serve on the utilization review and/or quality management committee of such
programs in accordance with the procedures established by DAVIS and Plans. Failure to comply
with the requirements of this paragraph may be deemed by DAVIS to be a material breach of this
Agreement and may, at DAVIS’ option, be grounds for immediate termination by DAVIS of this
Agreement. PROVIDER agrees the decisions of the DAVIS designated utilization review and
quality management committees may be used by DAVIS to deny PROVIDER payment for services
rendered to a Member which are determined to not be Medically Appropriate or of poor quality or to
be services for which PROVIDER failed to receive a confirmation of eligibility prior to rendering
services.
.4 Grievance Procedures. Subject to PROVIDER’s rights of appeal, PROVIDER
shall comply and be bound by the grievance procedure which, in the sole discretion of DAVIS and
Plan(s) shall be established in accordance with applicable statutes and their implementing
regulations for the processing of any patient or PROVIDER complaint regarding Covered Services.
From time to time, should the grievance procedure require modification whether by DAVIS or
Plan(s), it shall be modified in accordance with applicable regulations and Section V.3 “Compliance
with Davis and Plan Rules” herein.
.5 Member Grievance Resolution. PROVIDER shall cooperate with DAVIS in
the investigation of any complaint regarding the materials or services provided by PROVIDER.
The cost of providing replacement services or materials to satisfy any reasonable Member complaint
shall be borne by PROVIDER if the grievance is determined to be the result of improper execution
of services on the part of PROVIDER or if materials are not functioning in the manner prescribed
by the Participating Provider(s) and/or the professional staff.
.6 Provider Cooperation with External Review. PROVIDER shall cooperate and
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25
provide Plans, DAVIS, government agencies and any external review organizations (“Oversight
Entities”) with access to each Member’s vision records for the purposes of quality assessment,
service utilization and quality improvement, investigation of Member(s)’ complaints or grievances
or as otherwise is necessary or appropriate.
.7 Provider Participation/Cooperation with UR/QM Programs. As applicable,
PROVIDER agrees to participate in, cooperate and comply with, and abide by decisions of DAVIS,
MCO, and/or Plan(s) with respect to DAVIS’, MCO’s, and/or Plan(s)’ medical policies and medical
management programs, procedures or activities; quality improvement and performance improvement
programs, procedures and activities; and utilization and management review; care coordination
activities including, but not limited to, medical record reviews, HEDIS reporting, disease
management programs, case management, clinical practice guidelines, and other quality
measurements to improve Members’ care. PROVIDER further agrees to comply and cooperate
with an independent quality review and improvement organization’s activities pertaining to the
provision of Covered Services for Medicare, Medicare Advantage, and Medical Assistance Program
Members. PROVIDER shall implement a continuous quality improvement action plan if areas for
improvement are identified.
X
GENERAL PROVISIONS
.1 Arbitration. Any controversy or claim arising out of or relating to this
Agreement, or to the breach thereof, will be settled by arbitration in accordance with the commercial
arbitration rules of the American Arbitration Association, and judgment upon the award rendered by
the arbitrator(s) may be entered in any court having jurisdiction thereof. Such arbitration shall occur
within the State of New York, unless the Parties mutually agree to have such proceedings in some
other locale. In any such proceeding, the arbitrator(s) may award attorneys' fees and costs to the
prevailing Party.
.2 Assignment. This Agreement shall be binding upon, and shall inure to the benefit
of the Parties to it and to their respective heirs, legal representatives, successors, and permitted
assigns. Notwithstanding the foregoing, neither Party may assign any of his/her/its rights or delegate
any of his/her/its duties hereunder without receiving the prior, written consent of the other Party,
except that DAVIS may assign this Agreement to a controlled subsidiary or affiliate or to any
successor to its business, by merger or consolidation, or to a purchaser of all or substantially all of
DAVIS’ assets.
.3 Confidentiality of Terms/Conditions. The terms of this Agreement and in
particular the provisions regarding compensation are proprietary and confidential and shall not be
disclosed except as and only to the extent necessary to the performance of this Agreement or as
required by law.
.4 Conformity of Law. Any provision of this Agreement which conflicts with state
or federal law is hereby amended to conform to the requirements of such law.
.5 Entire Agreement of the Parties. This Agreement supersedes any and all
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26
agreements, either written or oral, between the Parties hereto with respect to the subject matter
contained herein and contains all of the covenants and agreements between the Parties with respect
to the rendering of Covered Services. Each Party to this Agreement acknowledges that no
representations, inducements, promises, or agreements, oral or otherwise, have been made by either
Party, or anyone acting on behalf of either Party, which are not embodied herein, and that no other
agreement, statement, or promise not contained in this Agreement shall be valid or binding. Except
as otherwise provided herein, any effective modification must be in writing and signed by the Party
to be charged.
.6 Governing Law. This Agreement shall be governed by and construed in
accordance with the laws of the state in which PROVIDER maintains his, her, or its principal office
or, if a dispute concerns a particular Member, in the state in which PROVIDER rendered services to
that Member.
.7 Headings. The subject headings of the sections and sub-sections of this
Agreement are included for purposes of convenience only and shall not affect the construction or
interpretation of any of the provisions of this Agreement.
.8 Independent Contractor. At all times relevant to and pursuant to the terms and
conditions of this Agreement, PROVIDER is and shall be construed to be an independent contractor
practicing PROVIDER’s profession and shall not be deemed to be or construed to be an agent,
servant or employee of DAVIS.
.9 Non-Solicitation of Members. During the Term of this Agreement and for a
period of two (2) years after the effective date of termination of this Agreement, PROVIDER shall
not directly or indirectly engage in the practice of solicitation of Members, Plans or any employer of
said Members without DAVIS’ prior written consent. For purposes of this Agreement, a solicitation
shall mean any action by PROVIDER which DAVIS may reasonably interpret to be designed to
persuade or encourage (i) a Member or Plan to discontinue his/her/its relationship with DAVIS or
(ii) a Member or an employer of any Member to disenroll from a Plan contracting with DAVIS. A
breach of this paragraph shall be grounds for immediate termination of this Agreement.
.10 Notices. Should either Party be required or permitted to give notice to the other
Party hereunder, such notice shall be given in writing and shall be delivered personally or by first
class mail to the addresses appearing herein. Notices delivered personally will be deemed
communicated as of actual receipt. Notices delivered via first class mail shall be deemed
communicated as of three (3) days after mailing. Either Party may change its address by providing
written notice in accordance with this paragraph.
.11 Proprietary Information. PROVIDER shall maintain the confidentiality of all
information obtained directly or indirectly through his/her/its participation with DAVIS regarding a
Member, including but not limited to, the Member’s name, address and telephone number (“Member
Information”), and all other “DAVIS trade secret information”. For purposes of this Agreement,
“DAVIS trade secret information” shall include but shall not be limited to: (i) all DAVIS Plan
agreements and the information contained therein regarding DAVIS, Plans, employer groups, and
the financial arrangements between any hospital and DAVIS or any Plan and DAVIS, and (ii) all
122309
27
manuals, policies, forms, records, files (other than patient medical files), and lists of DAVIS.
PROVIDER shall not disclose or use any Member Information or DAVIS trade secret information
for his/her/its own benefit or gain either during the Term of this Agreement or after the date of
termination of this Agreement; provided, however, that PROVIDER may use the name, address and
telephone number, and/or medical information of a Member if Medically Appropriate for the proper
treatment of such Member or upon the express prior written permission of DAVIS, the Plan in which
the Member is enrolled, and the Member.
.12 Severability. Should any provision of this Agreement be held to be invalid,
void or unenforceable by a court of competent jurisdiction or by applicable state or federal law and
their implementing regulations, the remaining provisions of this Agreement will nevertheless
continue in full force and effect.
.13 Third Party Beneficiaries.
(a) Plans. Plans are intended to be third party beneficiaries of this
Agreement. Plans shall be deemed, by virtue of this Agreement to have privity of contract with
PROVIDER and may enforce any of the terms hereof.
(b) Other Persons. Other than the Plans and the Parties hereto and their
respective successors or assigns, nothing in this Agreement whether express or implied, or by reason
of any term, covenant, or condition hereof, is intended to or shall be construed to confer upon any
person, firm, or corporation, any remedy or any claim as third party beneficiaries or otherwise; and
all of the terms, covenants, and conditions hereof shall be for the sole and exclusive benefit of the
Parties hereto and their successors and assigns.
.14 Use of Name. DAVIS reserves the right to the control and to the use of its
name(s) and all copyright(s), symbol(s), trademark(s) or service mark(s) presently existing or later
established. PROVIDER shall not use DAVIS’ or any Plan’s name(s), tradename(s), trademark(s),
symbol(s), logo(s), or service mark(s) without the prior, written authorization of DAVIS or such
Plan.
.15 Waiver. The waiver of any provision or the waiver of any breach of this
Agreement must be set forth specifically in writing and signed by the waiving Party. Any such
waiver shall not operate as or be deemed to be a waiver of any prior or any future breach of such
provision or of any other provision contained herein.
-SIGNATURE PAGE TO FOLLOW-
122309
28
IN WITNESS WHEREOF, the Parties have set their hand hereto and this Agreement is
effective as of the Effective Date written below.
PROVIDER:
Signature:
Print Name:
Print Title:
Print Date:
Print All Addresses Below [complete addresses for all practice locations]:
Address 1:
Address 2:
Address 3:
Address 4:
Address 5:
(PROVIDER MUST sign and complete all spaces below PROVIDER signature.)
* Submission of a completed credentialing application and/or submission of a signed Participating Provider Agreement does not
constitute acceptance as a DAVIS Participating Provider. Acceptance as a Participating Provider is contingent on the acceptance by
DAVIS of practitioner’s fully and properly completed credentialing application and on the execution by practitioner of the
Participating Provider Agreement and on the receipt by practitioner of the forms, manual and samples required for participation.
DAVIS reserves the absolute right to determine which practitioner is acceptable for participation and in which groups a practitioner
will participate. Following DAVIS’ acceptance of a practitioner as a Participating PROVIDER, should additional licensed and
credentialed practitioner(s) join PROVIDER’s practice and provide Covered Services to the Members of Plans under Plan
Contract(s) with DAVIS, such additional practitioner(s) shall be subject to and bound by each and every term and condition set forth
in this Agreement to the same extent as the original signatories to this Agreement.
DAVIS VISION, INC.:
Signature:
Print Name: Nate Kenyon
Print Title: VP, Network Management
Date:
[For DAVIS use only]
Effective Date:
[For DAVIS use only]
Notes:
[For DAVIS use ONLY]
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29
Provider Add Form

New Office Location
 Adding Doctor to Existing Location DV Provider#______
Provider Information
Last Name:
First Name:
Title (Circle one):
MD DO OD
SSN:
DOB:
Sex (Circle one):
Individual NPI #:
Medicaid #
(Individual):
CAQH #:
Group/Office Name:
Group NP I#:
Office Address:
Office city, State, Zip:
Office Phone #:
Office
E-Mail address:
Office Fax #:
Medicaid #
(Group):
M
F
Please note: CAQH attestation must be signed and dated
within the past 30 days
Please attach W-9 for billing address (Name/Address to send Check Payments)
Materials shipping street address: _______________________________________________________
City: ____________________________ State: _______ Zip: ___________ Country: __________
Please select below the services provided by your office:
____ Full Service (Exam, Eyeglasses & CLs)
____ Exam Only
____ Eyeglasses & Contact Lenses
____ Exam & Contact Lenses
____ Eyeglasses Only
____ Exam & Glasses
____ Contact Lenses
____ Laser Surgery
Languages Spoken:
☐ English ☐ American Sign ☐ Spanish
Hours of Operation:
Monday
Tuesday
Wednesday
☐ Other_________________________
Thursday
Friday
Saturday
Sunday
Attestation:
I understand and acknowledge that neither the submission of a completed Davis Vision, Vision Care Provider
Application nor the execution of the Davis Vision Participating Provider Agreement constitutes acceptance as a
Davis Vision Participating Provider. Acceptance as a Davis Vision Participating Provider is contingent on the
acceptance by Davis Vision, Inc. of an applicant’s completed Application, and on the execution by the applicant of
the Davis Vision Participating Provider Agreement, and on the receipt by the applicant of the forms, manual and
samples required for participation. Davis Vision, Inc. reserves the absolute right to determine which applicant is
acceptable for participation and in which groups an applicant will participate.
*Signature: _________________________________________________Date: ____________
*Print Name: _____________________________________*(Must sign and print name in full.)
Submit completed requests to Network Development by fax to 1-888-553-2847
WCR

W Welc ome e to o Da avis Vis sion !

Transcription

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