Credentialing Packet
Packet may be submitted via the following:
Email:
Fax:
Mail:
DentalNetwork@EnvolveHealth.com
1-855-475-4374
Envolve Dental, Inc.
P
.O. Box 25656
Tampa, FL 33622
Checklist:
Provider Credentialing Application
Malpractice Insurance
DEA and/or CDS Certificate or copy DEA/CDS Waiver
State License
Disclosure of Ownership Form (If Applicable)
Electronic Health Record Form (If Applicable)
Copy of Anesthesia Permit (If Applicable)
Copy of EBO Statement of Inpatient Admission Coverage (if Oral Surgeon does not have
hospital privileges
Pursuant to Texas Insurance Code § 1452.052, LHL234 Rev. 01/07 is promulgated by the Texas Department of Insurance. Please send this
application to the carrier with whom you wish to become credentialed.
Texas Standardized Credentialing Application (Please type or print)
LHL234 Rev.01/07 1 of 20
Section I-Individual Information
TYPE OF PROFESSIONAL
LAST NAME FIRST MIDDLE (JR., SR., ETC.)
MAIDEN NAME YEARS ASSOCIATED (YYYY-YYYY)
OTHER NAME YEARS ASSOCIATED (YYYY-YYYY)
HOME MAILING ADDRESS
CITY STATE/COUNTRY POSTAL CODE
HOME PHONE NUMBER
SOCIAL SECURITY NUMBER
Female Male
CORRESPONDENCE ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX NUMBER
E-MAIL
DATE OF BIRTH (MM/DD/YYYY)
PLACE OF BIRTH
CITIZENSHIP
IF NOT AMERICAN CITIZEN, VISA NUMBER & STATUS
ARE YOU ELIGIBLE TO WORK IN THE UNITED STATES?
Yes No
U.S.MILITARY SERVICE/PUBLIC HEALTH
Yes No
DATES OF SERVICE (MM/DD/YYYY) TO
(MM/DD/YYYY)
LAST LOCATION
BRANCH OF SERVICE
ARE YOU CURRENTLY ON ACTIVE OR RESERVE MILITARY DUTY?
Yes No
Education
PROFESSIONAL DEGREE (MEDICAL, DENTAL, CHIROPRACTIC, ETC.)
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE
ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
Please check this box and complete and submit Attachment A if you received other professional degrees.
POST-GRADUATE EDUCATION SPECIALTY
Internship Residency Fellowship Teaching Appointment
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR
CURRENT PROGRAM DIRECTOR (IF KNOWN)
POST-GRADUATE EDUCATION SPECIALTY
Internship Residency Fellowship Teaching Appointment
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
LHL234 Rev.01/07 2 of 20
Education
- continued
POST-GRADUATE EDUCATION
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR
CURRENT PROGRAM DIRECTOR (IF KNOWN)
Please check this box and complete and submit Attachment B if you received additional postgraduate training.
OTHER GRADUATE-LEVEL EDUCATION
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
Licenses and Certificates - Please include all license(s) and certifications in all States where you are currently or
have previously been licensed.
LICENSE TYPE
LICENSE NUMBER
STATE OF REGISTRATION
ORIGINAL DATE OF ISSUE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
DO YOU CURRENTLY PRACTICE IN THIS STATE?
Yes No
LICENSE TYPE
LICENSE NUMBER
STATE OF REGISTRATION
ORIGINAL DATE OF ISSUE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
DO YOU CURRENTLY PRACTICE IN THIS STATE?
Yes No
LICENSE TYPE
LICENSE NUMBER
STATE OF REGISTRATION
ORIGINAL DATE OF ISSUE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
DO YOU CURRENTLY PRACTICE IN THIS STATE?
Yes No
DEA Number:
ORIGINAL DATE OF ISSUE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
DPS Number:
ORIGINAL DATE OF ISSUE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
OTHER CDS (PLEASE SPECIFY)
NUMBER
STATE OF REGISTRATION
ORIGINAL DATE OF ISSUE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
DO YOU CURRENTLY PRACTICE IN THIS STATE?
Yes No
UPIN
NATIONAL PROVIDER IDENTIFIER (WHEN AVAILABLE)
ARE YOU A PARTICIPATING MEDICARE PROVIDER?
Yes No Medicare Provider Number:
ARE YOU A PARTICIPATING MEDICAID PROVIDER?
Yes No Medicare Provider Number:
EDUCATIONAL COUNCIL FOR FOREIGN MEDICAL GRADUATES (ECFMG)
N/A Yes No ECFMG Number:
ECFMG ISSUE DATE (MM/DD/YYYY)
Professional/Specialty Information
PRIMARY SPECIALTY
BOARD CERTIFIED?
Yes No Name of Certifying Board:
INITIAL CERTIFICATION DATE (MM/YYYY)
RECERTIFICATION DATE(S), IF APPLICABLE (MM/YYYY)
EXPIRATION DATE, IF APPLICABLE (MM/YYYY)
IF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT APPLY.
I have taken exam, results pending for Board.
I have taken Part I and am eligible for Part II of the Exam.
I am intending to sit for the Boards on (date)
I am not
p
lannin
g
to take Boards.
DO YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY?
HMO:
Yes No PPO: Yes No POS: Yes No
SECONDARY SPECIALTY
BOARD CERTIFIED?
Yes No Name of Certifying Board:
INITIAL CERTIFICATION DATE (MM/YYYY)
RECERTIFICATION DATE(S), IF APPLICABLE (MM/YYYY)
EXPIRATION DATE, IF APPLICABLE (MM/YYYY)
LHL234 Rev.01/07 3 of 20
Professional/S
p
ecialt
y
Information -continued
IF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT APPLY.
I have taken exam, results pending for Board.
I have taken Part I and am eligible for Part II of the Exam.
I am intending to sit for the Boards on (date)
I am not planning to take Boards.
DO YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY?
HMO:
Yes No PPO: Yes No POS: Yes No
ADDITIONAL SPECIALTY
BOARD CERTIFIED?
Yes No Name of Certifying Board:
INITIAL CERTIFICATION DATE (MM/YYYY)
RECERTIFICATION DATE(S), IF APPLICABLE (MM/YYYY)
EXPIRATION DATE, IF APPLICABLE (MM/YYYY)
IF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT APPLY.
I have taken exam, results pending for Board.
I have taken Part I and am eligible for Part II of the Exam.
I am intending to sit for the Boards on (date)
I am not planning to take Boards.
DO YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY?
HMO:
Yes No PPO: Yes No POS: Yes No
PLEASE LIST OTHER AREAS OF PROFESSIONAL PRACTICE INTEREST OR FOCUS (HIV/AIDS, ETC.)
Work History - Please provide a chronological work history. You may submit a Curriculum Vitae as
a supplement. Please explain all gaps in employment that lasted more than six months.
CURRENT PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE
MM/YYYY TO MM/YYYY
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE
(
MM/YYYY TO MM/YYYY
)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE
(
MM/YYYY TO MM/YYYY
)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PLEASE PROVIDE AN EXPLANATION FOR ANY GAPS GREATER THAN SIX MONTHS (MM/YYYY TO MM/YYYY) IN WORK HISTORY.
Gap Dates:
Explanation:
Gap Dates:
Explanation:
LHL234 Rev.01/07 4 of 20
Work History
– continued
Gap Dates: Explanation:
Gap Dates: Explanation:
Please check this box and complete and submit Attachment C if you have additional work history
Hospital Affiliations-Please include all hospitals where you currently have or have previously had privileges.
DO YOU HAVE HOSPITAL PRIVILEGES?
Yes No
IF YOU DO NOT HAVE ADMITTING PRIVILEGES, WHAT ADMITTING ARRANGEMENTS DO YOU HAVE?
PRIMARY HOSPITAL WHERE YOU HAVE ADMITTING PRIVILEGES
START DATE (MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX
E-MAIL
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
ARE PRIVILEGES TEMPORARY?
Yes No
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO PRIMARY HOSPITAL?
OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES
START DATE (MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX
E-MAIL
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
ARE PRIVILEGES TEMPORARY?
Yes No
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?
Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES
AFFILIATION DATES
(
MM/YYYY TO
MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.
References-Please provide three peer references from the same field and/or specialty who are not partners in your own group practice and are not
relatives. All peer references should have firsthand knowledge of your abilities.
1 NAME/TITLE
PHONE NUMBER
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
LHL234 Rev.01/07 5 of 20
References- continued
2 NAME/TITLE
PHONE NUMBER
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
3 NAME/TITLE
PHONE NUMBER
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Professional Liability Insurance Coverage
SELF-INSURED?
Yes No
NAME OF CURRENT MALPRACTICE INSURANCE CARRIER OR SELF-INSURED ENTITY
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
POLICY NUMBER
EFFECTIVE DATE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
AMOUNT OF COVERAGE PER
OCCURRENCE
AMOUNT OF COVERAGE AGGREGATE
TYPE OF COVERAGE
Individual Shared
LENGTH OF TIME WITH CARRIER
NAME OF PREVIOUS MALPRACTICE INSURANCE CARRIER IF WITH CURRENT CARRIER LESS THAN 5 YEARS
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
POLICY NUMBER
EFFECTIVE DATE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
AMOUNT OF COVERAGE PER
OCCURRENCE
AMOUNT OF COVERAGE AGGREGATE
TYPE OF COVERAGE
Individual Shared
LENGTH OF TIME WITH CARRIER
Call Coverage
See attached list of hospital staff within my department I utilize for call coverage.
PLEASE LIST NAMES OF COLLEAGUE(S) PROVIDING REGULAR COVERAGE AND HIS OR HER SPECIALTIES.
Name:
Specialty:
Name: Specialty:
Name: Specialty:
Name: Specialty:
Name: Specialty:
PLEASE LIST FULL NAMES OF ALL PARTNERS IN YOUR PRACTICE. CHECK THIS BOX AND ATTACH LIST FOR LARGE GROUP.
Name:
Name:
Name: Name:
Name: Name:
Name: Name:
LHL234 Rev.01/07 6 of 20
Practice Location Information - Please answer the following questions for each practice location. Use Attachment F or
make copies of pages 6-7 as necessary.
PRACTICE LOCATION
of
TYPE OF SERVICE PROVIDED
Solo Primary Care Solo Specialty Care Group Primary Care Group Single Specialty Group Multi-Specialty
GROUP NAME/PRACTICE NAME TO APPEAR IN THE DIRECTORY
GROUP/CORPORATE NAME AS IT APPEARS ON IRS W-9
PRACTICE LOCATION ADDRESS
Primary
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX NUMBER
E-MAIL
BACK OFFICE PHONE NUMBER
SITE-SPECIFIC MEDICAID NUMBER
TAX ID NUMBER
GROUP NUMBER CORRESPONDING TO TAX ID NUMBER
GROUP NAME CORRESPONDING TO TAX ID NUMBER
ARE YOU CURRENTLY PRACTICING AT THIS LOCATION?
Yes No
IF NO, EXPECTED START DATE? (MM/DD/YYYY)
DO YOU WANT THIS LOCATION LISTED IN THE
DIRECTORY?
Yes No
OFFICE MANAGER OR STAFF CONTACT
PHONE NUMBER
FAX NUMBER
CREDENTIALING CONTACT
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX NUMBER
E-MAIL
BILLING COMPANY'S NAME (IF APPLICABLE)
BILLING REPRESENTATIVE
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX NUMBER
E-MAIL
DEPARTMENT NAME IF HOSPITAL-BASED
CHECK PAYABLE TO
CAN YOU BILL ELECTRONICALLY?
Yes No
HOURS PATIENTS ARE SEEN
Monday
No Office Hours Morning: Afternoon: Evening:
Tuesday
No Office Hours Morning: Afternoon: Evening:
Wednesday No Office Hours Morning: Afternoon: Evening:
Thursday
No Office Hours Morning: Afternoon: Evening:
Friday
No Office Hours Morning: Afternoon: Evening:
Saturday
No Office Hours Morning: Afternoon: Evening:
Sunday
No Office Hours
Morning:
Afternoon:
Evening:
DOES THIS LOCATION PROVIDE 24 HOUR/7 DAY A WEEK PHONE COVERAGE?
Answering Service Voice mail with instructions to call answering service Voice mail with other instructions None
THIS PRACTICE LOCATION ACCEPTS
all new patients existing patients with change of payor new patients with referral new Medicare patients new Medicaid patients
IF NEW PATIENT ACCEPTANCE VARIES BY HEALTH PLAN, PLEASE PROVIDE EXPLANATION.
PRACTICE LIMITATIONS
Male only Female only Age: Other:
DO NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS, MIDWIVES, SOCIAL WORKERS OR OTHER NON-PHYSICIAN PROVIDERS CARE FOR PATIENTS AT THIS PRACTICE
LOCATION?
Yes No If yes, provide the following information for each staff member:
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
LHL234 Rev.01/07 7 of 20
Practice Location Information - continued
NAME PROFESSIONAL DESIGNATION STATE & LICENSE NUMBER
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
NON-ENGLISH LANGUAGES SPOKEN BY HEALTH CARE PROVIDERS
NON-ENGLISH LANGUAGES SPOKEN BY OFFICE PERSONNEL
ARE INTERPRETERS AVAILABLE?
Yes No If yes, please specify languages:
DOES THIS PRACTICE LOCATION MEET ADA ACCESSIBILITY STANDARDS?
Yes No
WHICH OF THE FOLLOWING FACILITIES ARE HANDICAPPED ACCESSIBLE?
Building Parking Restroom Other:
DOES THIS LOCATION HAVE OTHER SERVICES FOR THE DISABLED?
Text Telephony-TTY American Sign Language-ASL Mental/Physical Impairment Services 0ther:
IS THIS LOCATION ACCESSIBLE BY PUBLIC TRANSPORTATION?
Bus Regional Train Other:
DOES THIS LOCATION PROVIDE CHILDCARE SERVICES?
Yes No
DOES THIS LOCATION QUALIFY AS A MINORITY BUSINESS ENTERPRISE?
Yes No
WHO AT THIS LOCATION HAVE THE FOLLOWING CURRENT CERTIFICATIONS? (PLEASE LIST ONLY THE APPLICANT'S CERTIFICATION EXPIRATION DATES.)
Basic Life Support
Staff Provider Exp: Advanced Life Support in OB Staff Provider Exp:
Advanced Trauma Life Support
Staff Provider Exp: Cardio-Pulmonary Resuscitation Staff Provider Exp:
Advanced Cardiac Life Support
Staff Provider Exp: Pediatric Advanced Life Support Staff Provider Exp:
Neonatal Advanced Life Support
Staff Provider Exp: Other (please specify) Staff Provider Exp:
DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? Yes No
Laboratory Services; please list all Certificates of Participation (CLIA, AAFP, COLA, CAP, MLE):
DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? Yes No
X-ray; please list all certifications:
OTHER SERVICES
Radiology Services EKG Care of Minor Lacerations Pulmonary Function Tests
Allergy Injections Allergy Skin Tests Routine Office Gynecology Drawing Blood
Age Appropriate Immunizations Flexible Sigmoidoscopy Tympanometry/Audiometry Tests Asthma Treatments
Osteopathic Manipulations IV Hydration /Treatments Cardiac Stress Tests Physical Therapies
Other:
PLEASE LIST ANY ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)
IS ANESTHESIA ADMINISTERED AT THIS PRACTICE LOCATION?
Yes No Please specify the classes or categories:
WHO ADMINISTERS IT?
Please check this box and complete and submit Attachment F if you have other practice locations.
LHL234 Rev.01/07 8 of 20
Section II-Disclosure Questions
- Please provide an explanation for any question answered yes-except 16-on
page 10.
Licensure
1 Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted,
voluntarily surrendered while under investigation, or have you ever been subject to a consent order,
probation or any conditions or limitations by any state licensing board?
Yes No
2 Have you ever received a reprimand or been fined by any state licensing board?
Yes No
Hospital Privileges and Other Affiliations
3 Have your clinical privileges or Medical Staff membership at any hospital or healthcare institution ever
been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other
disciplinary conditions (for reasons other than non-completion of medical records when quality of
care was not adversely affected) or have proceedings toward any of those ends been instituted or
recommended by any hospital or healthcare institution, medical staff or committee, or governing
board?
Yes No
4 Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under
investigation?
Yes No
5 Have you ever been terminated for cause or not renewed for cause from participation, or been
subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or
provider organizations such as IPAs, PHOs)?
Yes No
Education, Training and Board Certification
6 Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign
during an internship, residency, fellowship, preceptorship or other clinical education program? If you
are currently in a training program, have you been placed on probation, disciplined, formally
reprimanded, suspended or asked to resign?
Yes No
7 Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status
as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical
education program?
Yes No
8 Have any of your board certifications or eligibility ever been revoked?
Yes No
9 Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while
under investigation?
Yes No
DEA or DPS
10 Have your Federal IDEA and/or DPS Controlled Substances Certificate(s) or authorization(s) ever been
denied, suspended, revoked, restricted, denied renewal, or voluntarily relinquished?
Yes No
Medicare, Medicaid or other Governmental Program Participation
11 Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned,
censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid
program, or in regard to other federal or state governmental health care plans or programs?
Yes No
Other Sanctions or Investigations
12 Are you currently or have you ever been the subject of an investigation by any hospital, licensing
authority, IDEA or DPS authorizing entities, education or training program, Medicare or Medicaid
program, or any other private, federal or state health program?
Yes No
LHL234 Rev.01/07 9 of 20
Section II - Disclosure Questions - continued
Other Sanctions or Investigations
13 To your knowledge, has information pertaining to you ever been reported to the National Practitioner
Data Bank or Healthcare Integrity and Protection Data Bank?
Yes No
14 Have you ever received sanctions from or been the subject of investigation by any regulatory
agencies (e.g., CLIA, OSHA, etc.)?
Yes No
15 Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital,
facility, or agency, or voluntarily terminated or resigned while under investigation by a hospital or
healthcare facility of any military agency?
Yes No
Malpractice Claims History
16 Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated,
mediated or litigated?
Yes No
If yes, please check this box and complete and submit Attachment G.
Criminal
17 Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony that is
reasonably related to your qualifications, competence, functions, or duties as a medical professional
Yes No
18 Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony including an
act of violence, child abuse or a sexual offense?
Yes No
19 Have you been court-martialed for actions related to your duties as a medical professional?
Yes No
Ability to Perform Job
20 Are you currently engaged in the illegal use of drugs? ("Currently" means sufficiently recent to justify a
reasonable belief that the use of drug 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.)
Yes No
21 Do you use any chemical substances that would in any way impair or limit your ability to practice
medicine and perform the functions of your job with reasonable skill and safety?
Yes No
Ability to Perform Job
22 Do you have any reason to believe that you would pose a risk to the safety or well-being of your
patients?
Yes No
23 Are you unable to perform the essential functions of a practitioner in your area of practice, with or
without reasonable accommodation?
Yes No
Please use the space on page 10 to explain yes answers to any question except #16.
LHL234 Rev.01/07 10 of 20
Section II - Disclosure Questions
-continued
Please use the space below to explain yes answers to any question except 16.
QUESTION NUMBER
PLEASE EXPLAIN
LHL234 Rev.01/07 11 of 20
Section IIIStandard Authorization, Attestation and Release (Not for Use for Employment Purposes)
I understand and agree that, as part of the credentialing application process for participation andor clinical privileges
(hereinafter, referred to as “Participation”) at or with
(PLEASE INDICATE MANAGED CARE COMPANY(S) OR HOSPITAL(S) TO WHICH YOU ARE APPLYING) (HEREINAFTER, INDIVIDUALLY REFERRED TO AS THE “ENTITY”)
and any of the Entity’s affiliated entities, I am required to provide sufficient and accurate information for a proper evaluation
of my current licensure, relevant training andor experience, clinical competence, health status, character, ethics, and any
other criteria used by the Entity for determining initial and ongoing eligibility for Participation. Each Entity and its
representatives, employees, and agent(s) acknowledge that the information obtained relating to the application process will
be held confidential to the extent permitted by law.
I acknowledge that each Entity has its own criteria for acceptance, and I may be accepted or rejected by each
independently. I further acknowledge and understand that my cooperation in obtaining information and my consent to the
release of information do not guarantee that any Entity will grant me clinical privileges or contract with me as a provider of
services. I understand that my application for Participation with the Entity is not an application for employment with the Entity
and that acceptance of my application by the Entity will not result in my employment by the Entity.
For Hospital Credentialing. I consent to appear for an interview with the credentials committee, medical staff executive
committee, or other representatives of the medical staff, hospital administration or the governing board, if required or
requested. As a medical staff member, I pledge to provide continuous care for my patients. I have been informed of existing
hospital bylaws, rules and regulations, and policies regarding the application process, and I agree that as a medical staff
member, I will be bound by them.
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 designated professional credentials verification
organization (collectively referred to as “Agents”), to investigate information, which includes both oral and written statements,
records, and documents, concerning my application for Participation. I agree to allow the Entity and/or its Agent(s) to inspect
all records and documents relating to such an investigation.
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 proceedings or prior to
the commencement of formal charges, but after I have knowledge that such formal charges were being (or are being)
contemplated and/or were (or are) in preparation.
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
APPLICANT’S INITIALS AND DATE (MMDDYYYY)
LHL234 Rev.01/07 12 of 20
Section IIIStandard Authorization, Attestation and Release–continued
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), andor 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 andor their auditors to
the extent required in connection with an audit of the credentialing processes and provided that the customer andor 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 true, correct, and complete to the best of my knowledge and
belief, and that I will notify the Entity andor its Agent(s) within 10 days of any material changes to the information I have
provided in my application or authorized to be released pursuant to the credentialing process. I understand that corrections to
the application are permitted at any time prior to a determination of Participation by the Entity, and must be submitted on-line
or in writing, and must be dated and signed by me (may be a written or an electronic signature). I understand and agree that
any material misstatement or omission in the application may constitute grounds for withdrawal of the application from
consideration; denial or revocation of Participation; andor immediate suspension or termination of Participation. This action
may be disclosed to the Entity andor its Agent(s).
I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release. I understand
and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.
SIGNATURE
NAME (PLEASE PRINT OR TYPE)
Last 4 digits of SSN or NPI (PLEASE PRINT OR TYPE)
DATE (MMDDYYYY)
Required Attachments or Supplemental InformationPlease attach hard copy or scanned documents of the following:
Copy of DEA or state DPS Controlled Substances Registration Certificate
Copy of other Controlled Dangerous Substances Registration Certificate(s)
Copy of current professional liability insurance policy face sheet, showing expiration dates, limits and applicant’s name
Copies of IRS W-9s for verification of each tax identification number used
Copy of workers compensation certificate of coverage, if applicable
Copy of CLIA certifications, if applicable
Copies of radiology certifications, if applicable
Copy of DD214, record of military service, if applicable
Reproduction of this form without any changes is allowed.
Notice About Certain Information Laws and Practices Pertaining to State Governmental Bodies (i.e. State Hospitals)
With few exceptions, you are entitled to be informed about the information that a state governmental body collects about
you (i.e. a state hospital). Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or
receive copies of information about yourself, including private information. However the state governmental body may
withhold information for reasons other than to protect your right to privacy. Under section 559.004 of the Texas Government
Code, you are entitled to request that the state governmental body correct information that it has about you that is incorrect.
For information about the procedure and costs for obtaining information, please contact the appropriate state governmental
body to which you have submitted this application.
LHL234 Rev.01/07 13 of 20
Texas Standardized Credentialing Application
Attachment A – Other Professional Degrees
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE
ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE
ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE
ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE
ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE
ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE
ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE
ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
LHL234 Rev.01/07 14 of 20
Texas Standardized Credentialing Application
Attachment B – Other Post Graduate Education
OTHER POST-GRADUATE EDUCATION SPECIALTY
Internship Residency Fellowship Teaching Appointment
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR
CURRENT PROGRAM DIRECTOR (IF KNOWN)
OTHER POST-GRADUATE EDUCATION SPECIALTY
Internship Residency Fellowship Teaching Appointment
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR
CURRENT PROGRAM DIRECTOR (IF KNOWN)
OTHER POST-GRADUATE EDUCATION SPECIALTY
Internship Residency Fellowship Teaching Appointment
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR
CURRENT PROGRAM DIRECTOR (IF KNOWN)
OTHER POST-GRADUATE EDUCATION SPECIALTY
Internship Residency Fellowship Teaching Appointment
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR
CURRENT PROGRAM DIRECTOR (IF KNOWN)
OTHER POST-GRADUATE EDUCATION SPECIALTY
Internship Residency Fellowship Teaching Appointment
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR
CURRENT PROGRAM DIRECTOR (IF KNOWN)
LHL234 Rev.01/07 15 of 20
Texas Standardized Credentialing Application
Attachment C – Other Work History
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
LHL234 Rev.01/07 16 of 20
Texas Standardized Credentialing Application
Attachment D – Other Current Hospital Affiliations
OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES
START DATE (MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX
E-MAIL
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
ARE PRIVILEGES TEMPORARY?
Yes No
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?
OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES
START DATE (MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX
E-MAIL
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
ARE PRIVILEGES TEMPORARY?
Yes No
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?
OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES
START DATE (MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX
E-MAIL
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
ARE PRIVILEGES TEMPORARY?
Yes No
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?
OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES
START DATE (MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX
E-MAIL
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
ARE PRIVILEGES TEMPORARY?
Yes No
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?
OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES
START DATE (MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX
E-MAIL
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
ARE PRIVILEGES TEMPORARY?
Yes No
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?
LHL234 Rev.01/07 17 of 20
Texas Standardized Credentialing Application
Attachment E – Other Previous Hospital Affiliations
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES
AFFILIATION DATES (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES
AFFILIATION DATES (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES
AFFILIATION DATES (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES
AFFILIATION DATES (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES
AFFILIATION DATES (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES
AFFILIATION DATES (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
LHL234 Rev.01/07 18 of 20
Texas Standardized Credentialing Application
Attachment F – Other Practice Locations
Practice Location Information - Please answer the following questions for each practice location. Use Attachment F or
make copies of pages 6-7 as necessary.
PRACTICE LOCATION
of
TYPE OF SERVICE PROVIDED
Solo Primary Care Solo Specialty Care Group Primary Care Group Single Specialty Group Multi-Specialty
GROUP NAME/PRACTICE NAME TO APPEAR IN THE DIRECTORY
GROUP/CORPORATE NAME AS IT APPEARS ON IRS W-9
PRACTICE LOCATION ADDRESS
Primary
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX NUMBER
E-MAIL
BACK OFFICE PHONE NUMBER
SITE-SPECIFIC MEDICAID NUMBER
TAX ID NUMBER
GROUP NUMBER CORRESPONDING TO TAX ID NUMBER
GROUP NAME CORRESPONDING TO TAX ID NUMBER
ARE YOU CURRENTLY PRACTICING AT THIS LOCATION?
Yes No
IF NO, EXPECTED START DATE? (MM/DD/YYYY)
DO YOU WANT THIS LOCATION LISTED IN THE
DIRECTORY?
Yes No
OFFICE MANAGER OR STAFF CONTACT
PHONE NUMBER
FAX NUMBER
CREDENTIALING CONTACT
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX NUMBER
E-MAIL
BILLING COMPANY'S NAME (IF APPLICABLE)
BILLING REPRESENTATIVE
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
FAX NUMBER
E-MAIL
DEPARTMENT NAME IF HOSPITAL-BASED
CHECK PAYABLE TO
CAN YOU BILL ELECTRONICALLY?
Yes No
HOURS PATIENTS ARE SEEN
Monday
No Office Hours Morning: Afternoon: Evening:
Tuesday
No Office Hours Morning: Afternoon: Evening:
Wednesday
No Office Hours Morning: Afternoon: Evening:
Thursday
No Office Hours Morning: Afternoon: Evening:
Friday
No Office Hours Morning: Afternoon: Evening:
Saturday
No Office Hours Morning: Afternoon: Evening:
Sunda
y
No Office Hours Mornin
g
: Afternoon:
Evenin
g
:
DOES THIS LOCATION PROVIDE 24 HOUR/7 DAY A WEEK PHONE COVERAGE?
Answering Service Voice mail with instructions to call answering service Voice mail with other instructions None
THIS PRACTICE LOCATION ACCEPTS
all new patients existing patients with change of payor new patients with referral new Medicare patients new Medicaid patients
IF NEW PATIENT ACCEPTANCE VARIES BY HEALTH PLAN, PLEASE PROVIDE EXPLANATION.
PRACTICE LIMITATIONS
Male only Female only Age: Other:
DO NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS, MIDWIVES, SOCIAL WORKERS OR OTHER NON-PHYSICIAN PROVIDERS CARE FOR PATIENTS AT THIS PRACTICE
LOCATION?
Yes No If yes, provide the following information for each staff member:
NAME PROFESSIONAL DESIGNATION STATE & LICENSE NUMBER
NAME PROFESSIONAL DESIGNATION STATE & LICENSE NUMBER
LHL234 Rev.01/07 19 of 20
Attachment F (continued)
Practice Location Information
- continued
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
NON-ENGLISH LANGUAGES SPOKEN BY HEALTH CARE PROVIDERS
NON-ENGLISH LANGUAGES SPOKEN BY OFFICE PERSONNEL
ARE INTERPRETERS AVAILABLE?
Yes No If yes, please specify languages:
DOES THIS PRACTICE LOCATION MEET ADA ACCESSIBILITY STANDARDS?
Yes No
WHICH OF THE FOLLOWING FACILITIES ARE HANDICAPPED ACCESSIBLE?
Building Parking Restroom Other:
DOES THIS LOCATION HAVE OTHER SERVICES FOR THE DISABLED?
Text Telephony-TTY American Sign Language-ASL Mental/Physical Impairment Services 0ther:
IS THIS LOCATION ACCESSIBLE BY PUBLIC TRANSPORTATION?
Bus Regional Train Other:
DOES THIS LOCATION PROVIDE CHILDCARE SERVICES?
Yes No
DOES THIS LOCATION QUALIFY AS A MINORITY BUSINESS ENTERPRISE?
Yes No
WHO AT THIS LOCATION HAVE THE FOLLOWING CURRENT CERTIFICATIONS? (PLEASE LIST ONLY THE APPLICANT'S CERTIFICATION EXPIRATION DATES.)
Basic Life Support
Staff Provider Exp: Advanced Life Support in OB Staff Provider Exp:
Advanced Trauma Life Support
Staff Provider Exp: Cardio-Pulmonary Resuscitation Staff Provider Exp:
Advanced Cardiac Life Support
Staff Provider Exp: Pediatric Advanced Life Support Staff Provider Exp:
Neonatal Advanced Life Support
Staff Provider Exp: Other (please specify) Staff Provider Exp:
DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? Yes No
Laboratory Services; please list all Certificates of Participation (CLIA, AAFP, COLA, CAP, MLE):
DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? Yes No
X-ray; please list all certifications:
OTHER SERVICES
Radiology Services EKG Care of Minor Lacerations Pulmonary Function Tests
Allergy Injections Allergy Skin Tests Routine Office Gynecology Drawing Blood
Age Appropriate Immunizations Flexible Sigmoidoscopy Tympanometry/Audiometry Tests Asthma Treatments
Osteopathic Manipulations IV Hydration /Treatments Cardiac Stress Tests Physical Therapies
Other:
PLEASE LIST ANY ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)
IS ANESTHESIA ADMINISTERED AT THIS PRACTICE LOCATION?
Yes No Please specify the classes or categories:
WHO ADMINISTERS IT?
Please check this box and complete and submit Attachment F if you have other practice locations.
LHL234 Rev.01/07 20 of 20
Texas Standardized Credentialing Application
Attachment G – Malpractice Claims History
INCIDENT DATE (MM/DD/YYYY)
DATE CLAIM WAS FILED (MM/DD/YYYY)
CLAIM/CASE STATUS
PROFESSIONAL LIABILITY CARRIER INVOLVED
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
POLICY NUMBER
AMOUNT OF AWARD OR SETTLEMENT & AMOUNT PAID
$ $
METHOD OF RESOLUTION
Dismissed
Settled (with prejudice)
Settled (without prejudice)
Judgment for Defendant(s)
Judgment for Plaintiff(s)
Mediation or Arbitration
DESCRIPTION OF ALLEGATIONS
WERE YOU PRIMARY DEFENDANT OR CO-DEFENDANT?
NUMBER OF OTHER CO-DEFENDANTS
YOUR INVOLVEMENT (ATTENDING, CONSULTING, ETC.)
DESCRIPTION OF ALLEGED INJURY TO THE PATIENT
TO THE BEST OF YOUR KNOWLEDGE, IS THIS CASE INCLUDED IN THE NATIONAL PRACTITIONER DATA BANK (NPDB)?
Yes No
INCIDENT DATE (MM/DD/YYYY)
DATE CLAIM WAS FILED (MM/DD/YYYY)
CLAIM/CASE STATUS
PROFESSIONAL LIABILITY CARRIER INVOLVED
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER
POLICY NUMBER
AMOUNT OF AWARD OR SETTLEMENT & AMOUNT PAID
$ $
METHOD OF RESOLUTION
Dismissed
Settled (with prejudice)
Settled (without prejudice)
Judgment for Defendant(s)
Judgment for Plaintiff(s)
Mediation or Arbitration
DESCRIPTION OF ALLEGATIONS
WERE YOU PRIMARY DEFENDANT OR CO-DEFENDANT?
NUMBER OF OTHER CO-DEFENDANTS
YOUR INVOLVEMENT (ATTENDING, CONSULTING, ETC.)
DESCRIPTION OF ALLEGED INJURY TO THE PATIENT
TO THE BEST OF YOUR KNOWLEDGE, IS THIS CASE INCLUDED IN THE NATIONAL PRACTITIONER DATA BANK (NPDB)?
Yes No
DEA/CDS RELEASE
I, _____________________, Dental license number ___________ do
not hold a DEA and/or CDS license in the state of ______. I will not
prescribe any schedule II-V medications while practicing dentistry. If my
patients required a prescription for which a DEA and/or CDS is required,
I will refer patients to their existing primary care provider and/or
general dentist.
Last Name, First Name: __________________________
NPI: ____________________
Signature: ______________________ Date: _____________
DEA/CDS Orthodontist Release
I, , Dental license number do not hold a DEA/CDS
license in the state of . I will not prescribe any schedule II-V medications while practicing
dentistry. If my patients required a prescription for which a DEA/CDS is required, I will refer
patients to their existing primary care provider and/or general dentist.
Last, First Name:
NPI:
Signature: Date:
To whom it may concern-
Please see the attached Disclosure of Ownership form for your location. The State has requested that
this document be filled out and returned to us as quickly as possible as the final step in credentialing
for your providers.
Only one copy of the Disclosure of Ownership form needs to be completed per tax
entity.
Please return the completed form
to: Fax: 844-847-9807
-Or-
Email: dentalcredentialing@envolvehealth.com
Your assistance is greatly appreciated with this matter. If you have any questions please call our toll-free
number at 855-434-9245.
Sincerely,
Credentialing Department
Page 1 of 6
© 2019 Envolve Benefit Options Disclosure of Ownership and Control Interest Form
Disclosure of Ownership and Control Interest Form for
Envolve Benefit Options Providers and Vendors
Complete Sections A and B. A separate Disclosure Form must be completed for each TIN.
For complete Instructions and Definitions see pages 5-6.
Section A (Please answer all of the following):
If you answered Yes to any questions, complete the Table(s) indicated, then sign the Attestation (Section B) on page 4
If you answered No to all questions, complete and sign the Attestation (Section B) on page 4
Section 1. Disclosure Regarding Managing Employees
Does the provider/vendor have any Managing Employees (CEO, Administrator, Director, COO, CFO,
etc.)? (42 C.F.R. § 455.104)
No
Yes
Complete Table 1
Section 2. Criminal Offense Disclosure
Has the provider/vendor, or any Person (individual or entity) Who Has Ownership or Controlling Interest
in the provider/vendor, or who is an Agent or Managing Employee of the provider/vendor, ever been
convicted of a criminal offense related to that person's involvement in any program established under
Titles XVIII (Medicare), XIX (Medicaid), XXI (SCHIP), or Title XX (Social Services Block Grants) since
the inception of those programs? Verify exclusion through the applicable federal and state specific
exclusion databases. (42 C.F.R. § 455.106)
No
Yes
Complete Table 2
Section 3. Person(s) with Ownership or Control Interest Disclosure
Are there any Persons (individual or entity) With an Ownership or Control Interest in the
provider/vendor? (42 C.F.R. 455.104)
No
Yes
Complete Table 3
Section 4. Direct or Indirect Ownership of 5% or More in a Subcontractor Disclosure
Does the provider/vendor have an Ownership Interest or Indirect Ownership Interest of 5% or more in
any Subcontractor? (42 C.F.R. 455.104)
No
Yes
Complete Tables 4, 4A
Section 5. Other Disclosing Entity Disclosure
Does the provider/vendor or any one named in Table 3 have an Ownership or Control Interest in any
other Medicaid provider? (42 C.F.R. 455.104)
No
Yes
Complete Table 5
5A. Does the provider/vendor or any one named in Table 3 have an Ownership or Control Interest in
any other disclosing entity that does not participate in Medicaid but is required to disclose certain
ownership and control information because of participation in any of the programs established under Title
V (Maternal and Child Health Services Block Grant), XVIII (Medicare), XX (Block Grants to States for
Social Services), or Title XXI (State Children’s Health Insurance Program) of the Social Security Act?
(42 C.F.R. 455.104)
No
Yes
Complete Table 5
Section 6. Business Transactions Disclosure
Business Transactions - Subcontractors: Has the provider/vendor had any business transactions with
a Subcontractor totaling more than $25,000 in the previous twelve (12) month period (12- month period
ending as of the date on this request)? (42 C.F.R. 455.105)
No
Yes
Complete Table 6
Section 7. Significant Business Transaction Disclosure
Significant Business Transactions: Has the provider/vendor had any Significant Business
Transactions with a Wholly Owned Supplier or Subcontractor during the previous 5-year period (5-year
period ending as of the date on this request)?
No
Yes
Complete Table 7