APPLICATION 1 PRACTITIONER SHORT FORM

Transcription

1 Practitioner Checklist for Credentialing STOP! Use this form only if you have CAQH identification. Dear Practitioner: Thank you for your interest in becoming a provider for AlphaCare of New York, Inc. In accordance with our commitment to the quality of health care services delivered to our members, we have a well-defined and structured facility/provider credentialing process in place that you will need to undergo before we may confirm you as a provider. Please complete and submit the information requested in this form in its entirety within ten (10) business days, and return it to us either by fax to , to provrel@alphacare.com or by mail to the following address: Attn: Network & Provider Relations Department AlphaCare of New York, Inc. 335 Adams Street, Suite 2600 Brooklyn, NY Documents Signed Contract with AlphaCare of New York, Inc. Signed Exhibit B-1 Certification Regarding Lobbying Completed Application 1 Short Form CAQH provider registration number ADA Attestation/Checklist W-9 Malpractice Coverage Certificate Page Proof of completion of CMS approved HIPAA, Fraud, Waste & Abuse Training- Practitioner Application Short Form Page 1 of 5

2 For Credentialing Purposes To begin your credentialing process, please use this simple form. Please note that the top portion of this form is required information. If you are registered with CAQH Universal Credentialing Data Source, please contact CAQH to authorize AlphaCare of New York, Inc. access to provider s credentialing file. A. GENERAL INFORMATION TODAY S DATE DATE OF BIRTH SEX SOCIAL SECURITY LAST NAME FIRST NAME MIDDLE INITIAL PRIMARY PHONE NO. PRIMARY FAX NO. OFFICE ADDRESS PRIMARY PRACTICE NAME: PRIMARY OFFICE STREET ADDRESS PRIMARY OFFICE CITY STATE COUNTY ZIP CODE B. ADDITIONAL LOCATIONS SECOND OFFICE STREET ADDRESS SECOND OFFICE CITY STATE COUNTY ZIP CODE SECONDARY PHONE NO. SECONDARY FAX NO. SECONDARY ADDRESS THIRD OFFICE STREET ADDRESS THIRD OFFICE CITY STATE COUNTY ZIP CODE THIRD PHONE NO. THIRD FAX NO. THIRD ADDRESS FOURTH OFFICE STREET ADDRESS FOURTH OFFICE CITY STATE COUNTY ZIP CODE FOURTH PHONE NO. FOURTH FAX NO. FOURTH ADDRESS Practitioner Application Short Form Page 2 of 5

3 C. BILLING INFORMATION BILLING GROUP NAME (TO WHOM PAYMENTS GO) TIN # (ATTACH W-9) BILLING ADDRESS (WHERE PAYMENTS GO) BILLING CITY, STATE, ZIP CODE PROVIDER TYPE: (MD, DO, DC, NP, DPM, DMD, PT, ST, OT, ETC): PRIMARY SPECIALTY SECONDARY SPECIALTY ARE YOU BOARD CERTIFIED: YES NO IF YES, BOARD NAME: D. CONTACT INFORMATION PRIMARY CONTACT TITLE PHONE FAX ADMINISTRATION TITLE PHONE FAX FINANCE/BILLING TITLE PHONE FAX E. COUNTIES SERVED BRONX MANHATTAN QUEENS BROOKLYN WESTCHESTER F. HOURS OF OPERATION SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY G. LANGUAGES SPOKEN CHINESE RUSSIAN SPANISH OTHER (LIST): H. ACCREDITION, CERTIFICATION, LICENSURE AND ESSENTIAL INFORMATION ARE YOU REGISTERED WITH CAQH? YES NO IF YES, CAQH PROVIDER ID: IF NO, DO YOU WISH ALPHACARE OF NEW YORK, INC TO GENERATE A CAQH NUMBER FOR YOU? YES NO Practitioner Application Short Form Page 3 of 5

4 PRIMARY FAX NO.: ADDRESS: SOCIAL SECURITY NUMBER: DEA CERTIFICATE NO.: LICENSE/REGISTRATION NO.: LICENSED STATE: MEDICARE NUMBER: MEDICAID NUMBER: NPI NO. TIN NO. I. WORK HISTORY (FOR LAST 10 YEARS) PROVIDE A CURRICULUM VITAE (OR RESUME) OR FILL IN THE WORK HISTORY BELOW. J. SIGNATURE SIGNATURE I hereby affirm that the information provided by our institution to AlphaCare of New York, Inc. is accurate to the best of my knowledge and is furnished in good faith. I understand that willful and substantial omissions or misrepresentations may result in denial or suspension from providing services to AlphaCare of New York, Inc. members. Name: (Print) Signature: Date: ALPHACARE OF NEW YORK, INC. INTERNAL PURPOSES ONLY Section 1 should be completed by Provider Relations-Illegible forms will be returned) CONTRACT TYPE CONTRACT NAME/LEGAL NAME Individual Practitioner Group Practice Facility, Ancillary Services or Vendor CONTRACT EFFECTIVE DATE (REQUIRED) Practitioner Application Short Form Page 4 of 5

5 PAGE LEFT INTENTIONALLY BLANK IF ADDITIONAL SPACE IS NEEDED BY PROVIDER Practitioner Application Short Form Page 5 of 5