Data Application ATTN: ALL PROVIDERS COMPLETE THIS APPLICATION ENTIRELY. Legal Name:

Transcription

1 Data Application ATTN: ALL PROVIDERS COMPLETE THIS APPLICATION ENTIRELY Legal Name: Provider Type: D.O. M.D. CNM N.P. P.A. Other Suffix (Jr. III, etc.) Sex: M F Last Name First Name Middle Maiden Name No Middle Name: I attest that I do not have a middle name; above is my full legal name Other Former Names if applicable General Information: Active & Permanent Address Contact Number(s) for questions during our process Date of Birth State & Country of Birth / Social Security Number / / N.C. Medicare Individual ID, if applicable N.C. Medicaid Individual ID, if applicable (indicate if unknown) (indicate if unknown) REQUIRED: National Provider Identifier (NPI) NPI online User ID Password NEPN will maintain your online record. If you do not know your login/password, contact your current manager or call NPPES at , ask for a NPI Specialists to assist, or visit the NPPES website: Return all information and original signatures (no copies/faxes) to: Carolinas Medical Center-NorthEast ATTN: Jennifer Lambert 845 Church Street N, Suite 301 Concord, NC 28025

2 Data Application Application Attestation Statement You must sign and date this attestation page All information submitted by me in this application, as well as any attachments or supplemental information, is true, current, and complete to my best knowledge and belief as of the date of signature below. I fully understand that any significant misstatement in this application may constitute cause for denial of my application or termination of a resulting participation agreement. PRINT NAME OF PROVIDER SIGNATURE OF PROVIDER DATE HERE

3 ***Physicians*** Supporting Document Checklist You MUST Return Copies of the Following Items Current driver s license copy (required by Medicare to verify signature) Medical School Diploma (if framed, you may take a digital photo and it) ECFMG Certificate, if applicable CV updated to reflect Dates from the beginning of education up through your current status should be formatted as to-from and in month/year Explain all gaps greater than 1 month to briefly note reasons (i.e. studies, relocation, family related, etc.) Your current employment to date, and your anticipated end-date Add the practice name and tentative start date (mo/yr) for your new employment at Carolinas Medical Center Medical License, check one: NCMB New N.C. License application is in process (copy not yet available), application submitted to NCMB as of date Established N.C. License enclosed; I will submit the Address Change via website. Board Certification (if framed, you may take a digital photo and it): Board Certificate of your practicing specialty, if currently certified Board Certification Criteria Form (enclosed), only if you are not certified Internship and/or Residency Certificates or verification letter if new graduate, if eligible and not board certified -- *If currently completing Residency/Internship, provide an official from your specialty board indicating you have been accepted to sit for the Boards and the date of your examination (do not send the receipt). Fellowship Certificate or verification letter if new graduate, if applicable -- * If currently completing, provide an official from your specialty board indicating you have been accepted to sit for the Boards and the date of your examination If out of training for more than one year and not board certified, provide the following: Board Certification Criteria Form (enclosed) List of CME for the past 3 years, showing course name+ category+ hours+ date Copy of letter from specialty board confirming exam date Attach 3 professional references name and contact information, board certified in your specialty Provider Comments

4 DEA UPDATES Brand new applicant: I will apply for a DEA once my NC License is issued If you currently have a DEA registration: I agree to submit the online Registration Change Request at to update my DEA with the address of my new practice at Carolinas Medical Center (If you need that address, contact Jennifer Lambert at or jennifer.lambert@carolinashealthcare.org) -- OR -- I would like for Physician Services/Jennifer Lambert to submit the change of address online and I have signed the enclosed DEA Address Change Request If employed/working outside of N.C. until you relocate to Carolinas Medical Center: Current Employment End Date for last day of seeing patients at your location: I will continue to work at my current practice, prescribing under my DEA, until my employment with CHS. I understand that I must apply for a separate DEA due to payor requirements. (NorthEast Physician Network will pay for this one-time fee due to the credentialing requirements. Please contact Jennifer Lambert to discuss further if need.) Since you cannot change your DEA address until your current practice end-date, the DEA allows out-of-state providers to apply for a secondary/separate DEA for N.C. (this will prevent any delays with credentialing). Save your application receipt and return it with this paperwork, or you can forward it if you apply at a later date. We will reimburse you for the application fee. If under training: I am under a resident training DEA, facility DEA, or military only. I must apply for an individual DEA and agree to do so immediately at Continued

5 Carolinas Physicians Network (PHYSICIAN) BOARD CERTIFICATION CRITERIA FORM Please complete the following if you are NOT Board Certified in one or more specialties by a certifying board of the American Board of Medical Specialties, the American Osteopathic Association, the American Dental Association, the American Board of Oral and Maxillofacial Surgery or the American Board of Podiatric Surgery: Specialty 1 Specialty 2 1. Are you currently Board Certified by a YES NO YES NO Recognized American Specialty Board? If yes, please send us a copy of your Certificate 2. If not certified, have you met all of the YES NO YES NO residency training requirements for certification? 3. If not certified, are you actively working YES NO YES NO towards certification? (i.e: are you currently fulfilling the remaining requirements for certification?) 4. If not certified, have you previously taken the YES NO Exam Date(s) exam? (provide the exam dates) 5. When are you scheduled to take the board / / certification exam? (provide proof of Mo. Yr. Mo. Yr. application &/or acceptance to sit for the exam) Name of the Specialty Board(s) I certify that all the above information is complete and accurate to the best of my knowledge. Signature Date

6 *** Midlevel Provider Page *** Supporting Document Checklist You are Required to Return Copies of the Following Items CV with to/from and month/year format as well as all gaps greater than 30 days clarified Current driver s license College School Diploma: Master of Science in Nursing / Physician Assistant Program / Other NC License check all that apply: Submit Address Change via Physician Assistants New N.C. License is in process: application File ID#, to check status via Established License registration copy State of NC Medical Board Certificate State of NC Medical Board Initial Admission to Practice Nurse Practitioners Established License web printout NC Board of Nursing Initial Statement of Approval Letter (Nurse Practitioners) DEA Registration check all that apply: New DEA application, indicate if applied for or pending Established DEA Registration if established registration, Address Change confirmation printout, via (or) signed Address Change form is attached or N/A, no DEA Board Certification: Nurse Practitioners: ANCC, AANP, NCC, or PNP/N Physician Assistants: NCCPA Certificate and/or Card with valid expiration date