Fillable Credentialing Packet

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Credentialing Packet

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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 III–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 and⁄or 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 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, 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 (MM⁄DD⁄YYYY)
LHL234 Rev.01/07 12 of 20
Section III–Standard 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), 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 true, correct, and complete to the best of my knowledge and
belief, and that I will notify the Entity and⁄or 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; 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. 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 (MM⁄DD⁄YYYY)
Required Attachments or Supplemental Information–Please 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
Page 2 of 6
© 2019 Envolve Benefit Options Disclosure of Ownership and Control Interest Form
Table 1 Disclosure Regarding Managing Employees (Section 1; 42 C.F.R. § 455.104)
Provide the following details for any Managing Employee of the provider/vendor (See the definition of Managing Employee)
Name (First, Middle, Last)
SSN
Birthdate
Complete Address
(Street, City, State, Zip)
NPI
Position
(If applicable)
Table 2 Criminal Offense Disclosure (Section 2; 42 C.F.R. § 455.106)
Provide the following details and a description of offense(s). Use additional pages if necessary as set forth on page 4.
Name (First, Middle, Last)
SSN/TIN
Birthdate
Description
Table 3 Person(s) with Ownership or Control Interest Disclosure (Section 3; 42 C.F.R. § 455.104)
Provide the following details and include the title (for example, CEO, CFO, COO, owner, board member etc.). Please attach additional pages if necessary
as set forth on page 4. *For corporations/entities that have an ownership or control interest in the Disclosing Provider, please separately list its primary
business address, every business location and post office box address. (See the definition of a person with an ownership or control interest.)
Name (First, Middle, Last)
SSN/TIN
Birthdate
Title
Complete Address
(Street, City, State, Zip)
% Ownership
Interest
Table 3A Relationship Disclosure of Person(s) with Ownership (Section 3; 42 C.F.R. § 455.104)
Are any of the individuals disclosed in Table 3 related to each other as a spouse, parent, child, or sibling?
No ☐ N/A
☐ Yes - Provide the following details. Use additional pages if necessary as set forth on page 4.
Name (From Table 3)
How is the person in Table 3 related to the other
person who has ownership or controlling interest?
Name of Related Person listed in Table 3?
Table 3B Relationship Disclosure (Related to 4A) (Section 3; 42 C.F.R. § 455.104)
Are any of the individuals disclosed in Section 3 related to any of the individuals disclosed in Table 4A as a spouse, parent, child, or sibling?
No ☐ N/A
Yes - Provide the following details. Use additional pages if necessary as set forth on page 4.
Name (From Table 3)
How is the person from Table 3 related to the person
from Table 4A
Name of Related Person listed in Table 4A
Page 3 of 6
© 2019 Envolve Benefit Options Disclosure of Ownership and Control Interest Form
Table 4 Direct or Indirect Ownership of 5% or more in a Subcontractor Disclosure (Section 4;
42 C.F.R. § 455.104)
Provide the following details about the Subcontractor.
Name of Subcontractor
(First, Middle, Last)
SSN/TIN
Birthdate
Complete Address
(Street, City, State, Zip)
% Ownership
Interest
Table 4A Subcontractor Disclosure, Cont’d (Section 4; 42 C.F.R. § 455.104)
Provide the information below about any Person (individual or entity) with an Ownership or Control Interest in any Subcontractor in which the
provider/vendor has a 5% or more Ownership Interest or Indirect Ownership or Control Interest. (See the definition of the following terms: Person (individual
or entity) with an Ownership or Control Interest, Subcontractor and Indirect Ownership Interest.)
Name of Subcontractor
(From Table 4)
Name of Person(s)
with an ownership or
control interest in the
Subcontractor
SSN/TIN of
Person(s) with
an ownership or
control interest
in the
Subcontractor
Birthdate of
Person(s) with an
ownership or
control interest in
the Subcontractor
Complete Address (Street, City, State,
Zip) of Person(s) with an ownership or
control interest in the Subcontractor
% Ownership
Interest or
Control
Table 5 Other Disclosing Entity Disclosure (Sections 5, 5A; 42 C.F.R. § 455.104)
Provide the following details. (See the definition of the following terms: Other Disclosing Entity and Ownership Interest.)
Name(From Table 3)
Name of other disclosing entity or other Medicaid
Provider
SSN /TIN of the other disclosing entity or other Medicaid
Provider
Table 6 Business Transactions Disclosure (Section 6; 42 C.F.R. § 455.105)
Provide the following details. (See the definition of Subcontractor.)
Name of Subcontractor
TIN or SSN, of Subcontract
Birthdate
Complete Address
(Street, City, State, Zip)
Transaction
Amount
Table 7 Significant Business Transactions Disclosure (Section 7; 42 C.F.R. § 455.104)
Provide the following details. (See the definition of the following terms: Subcontractor, Wholly-owned Supplier, and Significant Business Transactions.)
Type of entity (Wholly Owned Supplier
OR Subcontractor)
Name
TIN/SSN
Birthdate
Complete Address
(Street, City, State, Zip)
Transaction
Amount
Page 4 of 6
© 2019 Envolve Benefit Options Disclosure of Ownership and Control Interest Form
Section B – Attestation
Name of Provider/Vendor (Disclosing Entity) Being Contracted:
Tax ID # of Provider/Vendor:
Complete Business Address (Street, City, State, Zip)
By signing below, I hereby certify that all information contained in this form is true, correct, and complete in all aspects. I understand that misleading,
inaccurate, or incomplete data may result in a denial of participation or termination of an existing contract.
Name: (Print or Type: First/Middle/Last)
Title: (Print or Type)
Authorized Signature:
Date:
By checking this box, I acknowledge I have completed the Provider Listing Form.
Additional Documentation
Are you uploading additional pages to this Form?
☐ Yes ☐ No
If you have indicated “Yes” above, attach additional pages using the link below:
Page 5 of 6
© 2019 Envolve Benefit Options Disclosure of Ownership and Control Interest Form
Appendix A - Instructions
1. Read all definitions and instructions outlined throughout this Form before completing. Terms that have regulatory definitions,
and in some cases helpful examples, are underlined throughout this Form. These Definitions can be found in Appendix B on
page 6. Please review the applicable definitions before responding to the question.
2. Answer all questions as of the current date.
3. If “No” is marked in any section, the corresponding table may be left blank. If “Yes” is marked in any section, all information
must be completed in the corresponding table. If there is no information to include in the table, indicate “None” or “N/A” in the
space provided. Do not leave blank spaces unless advised to do otherwise in the instructions. An incomplete Form will be
returned to the provider/vendor.
4. If more space is needed, please indicate at the bottom of page 4 that additional pages are attached, and use the link on page 4 to
upload the necessary file.
5. Business & Service Address: The address for corporate/legal entities must include, as applicable, the primary business address,
every business location, and P.O. Box address. Individuals must provide their home address.
6. This Form should be submitted at the time of contracting and within 35 calendar days of any change to the information reported
on this Form.
7. Failure to submit the requested information may result in denial of a claim, a refusal to enter into a provider agreement or
contract, or in termination of existing agreements and contract.
8. The following procedure and examples should be used to assist in determining direct and indirect ownership or control (42
C.F.R. § 455.102):
(a) Determining Indirect Ownership Interest. The amount of indirect ownership interest is determined by multiplying the
percentages of ownership in each entity. For example, if A owns 10 percent of stock in a corporation which owns 80
percent of the stock of the disclosing entity, A’s interest equates to an 8 percent indirect ownership interest in the disclosing
entity and must be reported. Conversely, if B owns 80 percent of the stock of a corporation which owns 5 percent of the
stock of the disclosing entity, B’s interest equates to a 4 percent indirect ownership interest in the disclosing entity and
need not be reported.
(b) Determining person with an ownership or control interest. In order to determine percentage of ownership, mortgage,
deed of trust, note, or other obligation, the percentage of interest owned in the obligation is multiplied by the percentage
of the disclosing entity’s assets used to secure the obligation. For example, if A owns 10 percent of a note secured by 60
percent of the provider’s assets, A’s interest in the provider’s assets equates to 6 percent and must be reported.
Conversely, if B owns 40 percent of a note secured by 10 percent of the provider’s assets, B’s interest in the provider’s
assets equates to 4 percent and need not be reported.
Page 6 of 6
© 2019 Envolve Benefit Options Disclosure of Ownership and Control Interest Form
Appendix B – Definitions (42 C.F.R. § 455.101)
Agent
Any person who has been delegated the authority to obligate or act on behalf of a provider. It also means any person who has express or implied
authority to obligate or act on behalf of an entity (42 CFR §§ 1001.2, 1001.1001).
Disclosing Entity
The provider or vendor contracting with Envolve Benefit Options (other than an individual practitioner).
Indirect Ownership Interest
An ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that
has an Indirect Ownership Interest in the disclosing entity. Indirect ownership interest includes an ownership interest through any other entities
that ultimately have an ownership interest in the entity in issue (42 CFR §§ 1001.2, 1001.1001).
Managing Employee
A general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who
directly or indirectly conducts the day-to-day operation of, an institution, organization, or agency.
Other Disclosing Entity
Any other disclosing entity and any 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, XVIII, or XX of the Act. This includes:
a. Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health
maintenance organization that participates in Medicare;
b. Any Medicare intermediary or carrier; and
c. Any entity (other than an individual practitioner) that furnishes, or arranges for the furnishing of, health-related services for which it claims
payment under any plan or program established under title V or title XX of the Act.
Ownership Interest
The possession of equity in the capital, the stock, or the profits of the disclosing entity. It also means an interest in:
a. The capital, the stock or the profits of the entity, or
b. Any mortgage, deed, trust or note, or other obligation secured in whole or in part by the property or assets of the entity. (42 CFR §§ 1001.2,
1001.1001).
Person with an Ownership or Control Interest
A person or corporation that:
a. Has an ownership interest totaling 5 percent or more in a disclosing entity;
b. Has an Indirect Ownership Interest equal to 5 percent or more in a disclosing entity;
c. Has a combination of direct and Indirect Ownership Interests equal to 5 percent or more in a disclosing entity;
d. Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest
equals at least 5 percent of the value of the property or assets of the disclosing entity;
e. Is an officer or director of a disclosing entity that is organized as a corporation; or
f. Is a partner in a disclosing entity that is organized as a partnership?
Significant Business Transaction
Any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a provider’s total
operating expenses.
Subcontractor
a. An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or
responsibilities of providing medical care to its patients; or
b. An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of
real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement.
Supplier
An individual, agency, or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid
(e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical firm).
Wholly Owned Supplier
A supplier whose total ownership interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a
provider.
Address
City
State
Zip Code
Office Contact Name
Telephone
Fax
Email
Office Hours Monday Tuesday Wednesday Thursday Friday Saturday
Provider Name Location Name Practice Tax ID Provider NPI Group NPI CAQH #
Provider
Medicaid ID
Group Medicaid
ID (Ohio Only)
Board
Certified
Yes or No
Sub-Specialty
(You must have
a Completion
Certificate)
Age
Limitation
Children &
Adults
Office
Handicap
Accessible
Yes or No
Sees patients
with special
needs
Yes or No
Languages
Spoken
Exhibit B
List of Contracted Providers
(List all Entities/Providers Affiliated with this Agreement)
Primary Practice Information
(If you have more than one location, please use the Location Roster Form - Excel Format.)
Contact Email
Contact Telephone
Number of Office Locations
03/2020
Medicaid
Ambetter
Allwell (Medicare)
Line of Business:
Ascension
© 2019 Envolve Dental, Inc. All rights reserved. ENVD EFT Form _Revised November 2019 current providers
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT
To enroll in Envolve Dental’s EFT payment program, complete this form and return it with a voided check via one of
the following:
Mail: Envolve Dental Fax: 855-475-4374 Email: providerrelations@envolvehealth.com
P.O. Box 25656
Tampa, FL, 33622-5656
I – CHECK APPLICABLE REASON FOR SUBMISSION
❑ New EFT Authorization OR ❑ EFT setup revision (e.g. account number or bank changes)
II – PROVIDER/PAYEE INFORMATION
Payee name: _________________________________________________________
Tax Identification Number (TIN): (Designate SSN ❑ or EIN ❑) _________________________________________________
Payee street address, City, State, Zip Code: ___________________________________________________________
III – DEPOSITORY INFORMATION (Financial Institution)
Your bank/depository name: ____________________________________
Account type (check one):
❑ Checking ❑ Savings
Depository routing transit number
(Nine digits. Include any leading zeroes):
________________________________
Depositor account number
(Include any leading zeroes):
______________________________
IV – CONTACT INFORMATION
Name of billing contact person:
Phone number of billing contact:_
Email address of billing contact:_
V – AUTHORIZATION
I hereby authorize Envolve Dental to initiate credit entries, and in accordance with 31 CFR part 210.6(f) initiate adjustments for any credit entries
made in error to the account indicated above. I hereby authorize the financial institution/bank named above, hereinafter called the DEPOSITORY, to
credit the same to such account. This authorization agreement is effective as of the signature date below and is to remain in full force and effect until
the CONTRACTOR has received written notification from me of its termination in such time and such manner as to afford the CONTRACTOR and the
DEPOSITORY a reasonable opportunity to act on it. The CONTACTOR will continue to send the direct deposit to the DEPOSITORY indicated above
until notified by me that I wish to change the DEPOSITORY receiving the direct deposit. If my DEPOSITORY information changes, I agree to submit
to the CONTRACTOR an updated EFT Authorization Agreement.
Signature of authorized billing contact: Date:
© 2019 Envolve Dental, Inc. All rights reserved. ENVD EFT Form _Revised November 2019 current providers
ELECTRONIC FUNDS TRANSFER (EFT) Terms of Use
The following terms and conditions, as amended from time to time (“Agreement”) apply to all use of the Envolve Dental’s Electronic Funds Transfer
solution, and the use of any service provided in connection therewith (collectively the “EFT Services”). In this Agreement, the words “you”, “your” and
“yours” means the individual(s) entity or entities identified on the attached Electronic Fund Transfer (EFT) Authorization Agreement, and the words “we,”
“our,” “us” refers to Envolve Dental affiliates and designees. Your enrollment or use of the EFT Services signifies your agreement to be legally bound by
the terms and conditions set forth herein. ACH and Wire Transfers. This Agreement is subject to Article 4A of the Uniform Commercial Code -- Funds
Transfers. By signing this Agreement, you authorize Envolve Dental, acting on behalf of any third party administrator, health care coalition, or health plan
carrier (each a “Carrier”) that participates in the EFT Services, to credit or debit the accounts listed on your Enrollment Form (the “Accounts”) in
connection with processing transactions between you and the Carriers. We may rely upon all Account information and identifying numbers provided by
you on the Authorization Agreement to receive payment. We may rely on the routing and account numbers you provided even if they identify a financial
institution, person or account other than the one named on the Enrollment Form You agree to be bound by National Automated Clearing House
Association (NACHA) rules. These rules provide, among other things, that payments made to you, are provisional until final settlement is made through a
Federal Reserve Bank or payment is otherwise made as provided in Article 4A-403(a) of the Uniform Commercial Code. If we do not receive such
payment, we are entitled to a refund from you in the amount credited to your Account and the Carrier that originated or instructed such payment will not
be considered to have paid the amount so credited. We are not required to give you any notice of debits or credits to your Accounts. We may make
adjustments to your Accounts whenever a correction or change is required. For example, if we make an error with respect to your Account, you agree
that we may correct such error immediately and without notice to you. Such errors may include, but are not limited to, reversing an improper credit to
your Account, making adjustments for returned items, and correcting calculation and input errors. Our right to make adjustments shall not be subject to any
limitations or time constraints, except as required by law. Accounts. You represent and warrant that (a) you are the owner of each of the Accounts and
(b) none of the Accounts is used primarily for personal, family or household purposes. Confidentiality. During the term of this Agreement, from time to
time, we may disclose or make available to you, whether orally, electronically or in physical form, confidential or proprietary information concerning us
and/or our business, products or services in connection with this Agreement(together, “Confidential Information”). Confidential Information includes,
without limitation, business plans, health plan relationships, acquisition plans, systems architecture, information systems, technology, data, computer
programs and codes, processes, methods, operational procedures, finances, budgets, policies and procedures, customer, employee, provider, member,
patient and beneficiary information, claims information, vendor information(including agreements, software and products), product plans, projections,
analyses, plans, results, and any other information which is normally and reasonably considered confidential. You agree that during the term of this
Agreement and thereafter: (i) you will use Confidential Information belonging to us solely for the purpose(s) of this Agreement; and (ii) you will take all
reasonable precautions to ensure that you do not disclose Confidential Information belonging to us to any third party (other than to your employees,
contractors and/or professional advisors on a need-to-know basis who are bound by obligations of nondisclosure and limited use precautions at least as
stringent as those contained herein) without first obtaining our written consent. Confidentiality Exclusions. For purposes hereof, “Confidential
Information” will not include any information that you can establish by convincing written evidence: (i) was independently developed by you without use
of or reference to any Confidential Information belonging to us; (ii) was acquired by you from a third party having the legal right to furnish same to the you
without disclosure restrictions; or (iii) was at the time in question (whether at disclosure or thereafter) generally known by or available to the public
(through no fault of you).Amendments and Termination. Envolve Dental may add, remove, change or otherwise modify any term of this Agreement at
any time. We may also terminate or discontinue some or all of the EFT Services at any time without notice to you. Governing Law and Venue. The laws
of the State of WI shall govern this Agreement and all disputes arising hereunder. You hereby consent that jurisdiction and venue are proper in the State
of WI for the resolution of any dispute arising under this Agreement. Severability. If any provision of this document is found to be unenforceable
according to its terms, all remaining provisions will continue in full force and effect. Headings. Headings in this document are for convenience or
reference only and will not govern the interpretation of the provisions. Construction. Except where it would be unreasonable or illogical to do so, words
and phrases used in this document should be construed so the singular includes the plural and the plural includes the singular. Cooperation. You agree
to cooperate fully with us in furnishing any information, documentation or performing any action requested by us. You shall furnish us, upon forty-eight
(48) hours notice, with true, accurate and complete copies of such records, documentation or any other information we or our authorized employees,
representatives, agents and any regulatory agencies may request; provided, however, that you shall not be required to divulge any records to the extent
prohibited by applicable law. Ownership. Except as provided in this Agreement, Envolve Dental shall have and own all rights, title and interests in the
EFT Services and any information arising from or in connection therewith. You hereby acknowledge the specific ownership interests of Envolve Dental
as set forth herein and you shall not acquire any ownership rights by virtue of this Agreement. Assignment. You agree not to assign this Agreement,
directly or by operation of law or subcontract, delegate or appoint any third-party agent to perform any or all of its duties obligations or services
hereunder without our written consent, and any such attempted assignment, subcontracting, delegation or appointment without such consent shall be
void. All written notices shall be delivered by registered or certified mail, return receipt requested, and shall be deemed effective seventy-two (72) hours
after the same is mailed via certified mail as described above with postage prepaid. Notice sent by any other method shall be effective only upon actual
receipt. The parties to this Agreement, by notice in writing, may designate another to whom notices shall be given pursuant to this Agreement.
Relationship of the Parties. The relationship between both parties under this Agreement is that of independent contractor. Nothing herein contained
shall be construed as constituting a partnership, joint venture or agency between the parties hereto. Entire Agreement. This Agreement, which is an
integral part hereof and are incorporated herein as a part of this Agreement, constitute the only agreement between the parties hereto relating to the
subject matter hereof, except where expressly noted herein, and all prior negotiations, agreements and understandings relating to the subject matter
hereof, whether oral or written, are superseded or canceled hereby. Force Majeure. Envolve Dental shall not be liable for a delay in performance or
failure to perform any obligation under this Agreement to the extent such delay is due to causes beyond our control, including, but not limited to,
governmental requests, regulations or orders, utility or communications failure, delays in transportation, national emergency, war, civil commotion or
disturbance, war conditions, fires, floods, storms, earthquakes, tidal waves, failure or delay in receiving electronic data, equipment or systems failure or
communication failures. Warranties. ENVOLVE DENTAL HEREBY DISCLAIMS ALL WARRANTIES WITH RESPECT TO THE SERVICES AND
PRODUCTS PROVIDEDHEREUNDER, WHETHER EXPRESS, IMPLIED, STATUTORY OR OTHERWISE, INCLUDING WITHOUT LIMITATION
ANYWARRANTY OFMERCHANTABILITY OR FITNESS FOR USE FOR A PARTICULAR PURPOSE. Under no circumstances shall the financial
responsibility of Envolve Dental for any failure of performance by us under this Agreement exceed the fees or charges paid by you to Envolve Dental for
the transaction, or activity that is or was the subject of the alleged failure of performance. IN NO EVENT SHALL ENVOLVE DENTAL, ITS
PARENT,AFFILIATES, SUBSIDIARIES, DIRECTORS, OFFICERS, EMPLOYEES, AGENTS OR REPRESENTATIVES BE LIABLE FOR
SPECIAL,INCIDENTAL OR CONSEQUENTIAL DAMAGES OR CLAIMS BY YOU OR ANY THIRD PARTY RELATIVE TO THE TRANSACTIONS HERE
UNDER. Indemnification. You shall be liable to and shall indemnify, defend and hold Envolve Dental its directors, officers, employees, representatives,
successors and permitted assigns harmless from and against any and all claims, demands by third parties, losses, liability, cost, damage and expense,
including litigation expenses and reasonable attorneys' fees and allocated costs for in-house legal services, to which Envolve Dental, its directors,
officers, employees, representatives, successors and permitted assigns may be subjected or which it may incur in connection with any claims which
arise from or out of or as the result of (a) your breach of this Agreement; (b) your performance, duties and obligations under this Agreement; or (c) the
negligence or willful misconduct of you, your directors, officers, employees, agents and affiliates in the performance of their duties and obligations under
this Agreement. You shall bear all risk of loss of items, records, data and materials during transit from you to Envolve Dental’s location or that of Envolve
Dental’s agents or sub-contractors. Waiver. No waiver or failure to exercise any option, right, or privilege under the terms of this Agreement on any
occasion or occasions shall be construed to be a waiver of the same or any other option, right or privilege on any other occasion.
Employer identification number
–
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
Social security number
–
–
TIN, later.
or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
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); and
4.
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
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 for Part II, later.
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
•
Form 1099-INT (interest earned or paid)
•
Form 1099-DIV (dividends, including those from stocks or mutual
funds)
•
Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
•
Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
•
Form 1099-S (proceeds from real estate transactions)
•
Form 1099-K (merchant card and third party network transactions)
•
Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
•
Form 1099-C (canceled debt)
•
Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X
Form W-9 (Rev. 10-2018)
Sign
Here
Signature of
U.S. person
▶
Date
▶
Print
or type.
See
Specific
Instructions
on page
3.
Form
W-9
(Rev. October 2018)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
▶
Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
following seven boxes.
Individual/sole proprietor or
C Corporation S Corporation Partnership Trust/estate
single-member LLC
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
▶
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions)
▶
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
(Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) See instructions.
Requester’s name and address (optional)
6 City, state, and ZIP code
7 List account number(s) here (optional)
Page 2
Form W-9 (Rev. 10-2018)
By signing the filled-out form, you:
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, and
4.
Certify that FATCA code(s) entered on this form (if any) indicating
that you are exempt from the FATCA reporting, is correct. See What is
FATCA reporting, later, for further information.
Note: If you are a U.S. person and 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 under section 1446 on any foreign partners’ share of effectively
connected taxable income from such business. Further, in certain cases
where a Form W-9 has not been received, the rules under section 1446
require a partnership to presume that a partner is a foreign person, and
pay the section 1446 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 section 1446 withholding on your share of
partnership income.
In the cases below, the following person must give 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.
•
In the case of a disregarded entity with a U.S. owner, the U.S. owner
of the disregarded entity and not the entity;
•
In the case of a grantor trust with a U.S. grantor or other U.S. owner,
generally, the U.S. grantor or other U.S. owner of the grantor trust and
not the trust; and
•
In the case of a U.S. trust (other than a grantor trust), the U.S. trust
(other than a grantor trust) and not the beneficiaries of the trust.
Foreign person. If you are a foreign person or the U.S. branch of a
foreign bank that has elected to be treated as a U.S. person, do not use
Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see
Pub. 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, give the requester the
appropriate completed Form W-8 or Form 8233.
Backup Withholding
What is backup withholding? Persons making certain payments to you
must under certain conditions withhold and pay to the IRS 24% 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, payments made in settlement of payment card and
third party network transactions, 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 instructions for
Part II 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 Exempt payee code, later, and the separate Instructions for the
Requester of Form W-9 for more information.
Also see Special rules for partnerships, earlier.
What is FATCA Reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a
participating foreign financial institution to report all United States
account holders that are specified United States persons. Certain
payees are exempt from FATCA reporting. See Exemption from FATCA
reporting code, later, and the Instructions for the Requester of Form
W-9 for more information.
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.
Page 3
Form W-9 (Rev. 10-2018)
name you entered on the Form 1040/1040A/1040EZ you filed with your
application.
b.
Sole proprietor or single-member LLC. Enter your individual
name as shown on your 1040/1040A/1040EZ on line 1. You may enter
your business, trade, or “doing business as” (DBA) name on line 2.
c.
Partnership, LLC that is not a single-member LLC, C
corporation, or S corporation. Enter the entity's name as shown on the
entity's tax return on line 1 and any business, trade, or DBA name on
line 2.
d.
Other entities. Enter your name as shown on required U.S. federal
tax documents on line 1. 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 line 2.
e.
Disregarded entity. For U.S. federal tax purposes, an entity that is
disregarded as an entity separate from its owner is treated as a
“disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter
the owner's name on line 1. The name of the entity entered on line 1
should never be a disregarded entity. The name on line 1 should be the
name shown on the income tax return on which the income should be
reported. For example, if a foreign LLC that is treated as a disregarded
entity for U.S. federal tax purposes has a single owner that is a U.S.
person, the U.S. owner's name is required to be provided on line 1. 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 line 2, “Business name/disregarded entity
name.” If the owner of the disregarded entity is a foreign person, the
owner must complete an appropriate Form W-8 instead of a Form W-9.
This is the case even if the foreign person has a U.S. TIN.
Line 2
If you have a business name, trade name, DBA name, or disregarded
entity name, you may enter it on line 2.
Line 3
Check the appropriate box on line 3 for the U.S. federal tax
classification of the person whose name is entered on line 1. Check only
one box on line 3.
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA reporting,
enter in the appropriate space on line 4 any code(s) that may apply to
you.
Exempt payee code.
•
Generally, individuals (including sole proprietors) are not exempt from
backup withholding.
•
Except as provided below, corporations are exempt from backup
withholding for certain payments, including interest and dividends.
•
Corporations are not exempt from backup withholding for payments
made in settlement of payment card or third party network transactions.
•
Corporations are not exempt from backup withholding with respect to
attorneys’ fees or gross proceeds paid to attorneys, and corporations
that provide medical or health care services are not exempt with respect
to payments reportable on Form 1099-MISC.
The following codes identify payees that are exempt from backup
withholding. Enter the appropriate code in the space in line 4.
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 U.S. commonwealth or
possession, or any of their political subdivisions or instrumentalities
4—A foreign government or any of its political subdivisions, agencies,
or instrumentalities
5—A corporation
6—A dealer in securities or commodities required to register in the
United States, the District of Columbia, or a U.S. commonwealth or
possession
7—A futures commission merchant registered with the Commodity
Futures Trading Commission
8—A real estate investment trust
9—An entity registered at all times during the tax year under the
Investment Company Act of 1940
10—A common trust fund operated by a bank under section 584(a) 11—
A financial institution
12—A middleman known in the investment community as a nominee or
custodian
13—A trust exempt from tax under section 664 or described in section
4947
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
Line 1
You must enter one of the following on this line; do not leave this line
blank. The name should match the name on your tax return.
If this Form W-9 is for a joint account (other than an account
maintained by a foreign financial institution (FFI)), list first, and then
circle, the name of the person or entity whose number you entered in
Part I of Form W-9. If you are providing Form W-9 to an FFI to document
a joint account, each holder of the account that is a U.S. person must
provide a Form W-9.
a. Individual. Generally, enter the name shown on your tax return. If
you have changed your last name without informing the Social Security
Administration (SSA) of the name change, enter your first name, the last
name as shown on your social security card, and your new last name.
Note: ITIN applicant: Enter your individual name as it was entered on
your Form W-7 application, line 1a. This should also be the same as the
IF the entity/person on line 1 is
a(n) . . .
THEN check the box for . . .
•
Corporation
Corporation
•
Individual
•
Sole proprietorship, or
•
Single-member limited liability
company (LLC) owned by an
individual and disregarded for U.S.
federal tax purposes.
Individual/sole proprietor or single-
member LLC
•
LLC treated as a partnership for
U.S. federal tax purposes,
•
LLC that has filed Form 8832 or
2553 to be taxed as a corporation,
or
•
LLC that is disregarded as an
entity separate from its owner but
the owner is another LLC that is
not disregarded for U.S. federal tax
purposes.
Limited liability company and enter
the appropriate tax classification.
(P= Partnership; C= C corporation;
or S= S corporation)
•
Partnership
Partnership
•
Trust/estate
Trust/estate
Page 4
Form W-9 (Rev. 10-2018)
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 13.
IF the payment is for . . .
THEN the payment is exempt
for . . .
Interest and dividend payments
All exempt payees except
for 7
Broker transactions
Exempt payees 1 through 4 and 6
through 11 and all C corporations.
S corporations must not enter an
exempt payee code because they
are exempt only for sales of
noncovered securities acquired
prior to 2012.
Barter exchange transactions and
patronage dividends
Exempt payees 1 through 4
Payments over $600 required to be
reported and direct sales over
$5,000
1
Generally, exempt payees
1 through 5
2
Payments made in settlement of
payment card or third party network
transactions
Exempt payees 1 through 4
1
See Form 1099-MISC, Miscellaneous Income, and its instructions.
2
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 reportable under section 6045(f), and
payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify
payees that are exempt from reporting under FATCA. These codes
apply to persons submitting this form for accounts maintained outside
of the United States by certain foreign financial institutions. Therefore, if
you are only submitting this form for an account you hold in the United
States, you may leave this field blank. Consult with the person
requesting this form if you are uncertain if the financial institution is
subject to these requirements. A requester may indicate that a code is
not required by providing you with a Form W-9 with “Not Applicable” (or
any similar indication) written or printed on the line for a FATCA
exemption code.
A—An organization exempt from tax under section 501(a) or any
individual retirement plan as defined in section 7701(a)(37)
B—The United States or any of its agencies or instrumentalities
C—A state, the District of Columbia, a U.S. commonwealth or
possession, or any of their political subdivisions or instrumentalities
D—A corporation the stock of which is regularly traded on one or
more established securities markets, as described in Regulations
section 1.1472-1(c)(1)(i)
E—A corporation that is a member of the same expanded affiliated
group as a corporation described in Regulations section 1.1472-1(c)(1)(i)
F—A dealer in securities, commodities, or derivative financial
instruments (including notional principal contracts, futures, forwards,
and options) that is registered as such under the laws of the United
States or any state
G—A real estate investment trust
H—A regulated investment company as defined in section 851 or an
entity registered at all times during the tax year under the Investment
Company Act of 1940
I—A common trust fund as defined in section 584(a) J—
A bank as defined in section 581
K—A broker
L—A trust exempt from tax under section 664 or described in section
4947(a)(1)
M—A tax exempt trust under a section 403(b) plan or section 457(g)
plan
Note: You may wish to consult with the financial institution requesting
this form to determine whether the FATCA code and/or exempt payee
code should be completed.
Line 5
Enter your address (number, street, and apartment or suite number).
This is where the requester of this Form W-9 will mail your information
returns. If this address differs from the one the requester already has on
file, write NEW at the top. If a new address is provided, there is still a
chance the old address will be used until the payor changes your
address in their records.
Line 6
Enter your city, state, and ZIP code.
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.
If you are a single-member LLC that is disregarded as an entity
separate from its owner, 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 What Name and Number To Give the Requester, later, 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 SSA 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. Go to www.irs.gov/Forms to view, download, or print Form W-
7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to
place an order and have Form W-7 and/or SS-4 mailed to you within 10
business days.
If you are asked to complete Form W-9 but do not have a TIN, apply
for a TIN and 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 U.S. 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, 4, or 5 below indicates 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 line 1 must sign. Exempt payees, see Exempt payee
code, earlier.
Signature requirements. Complete the certification as indicated in
items 1 through 5 below.
Page 5
Form W-9 (Rev. 10-2018)
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.
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 made in settlement of payment
card and third party network transactions, 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), ABLE accounts (under section 529A),
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 EIN of:
14. 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
The public entity
15. Grantor trust filing under the Form
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulations section 1.671-4(b)(2)(i)(B))
The trust
1
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.
2
Circle the minor’s name and furnish the minor’s SSN.
3
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, earlier.
*Note: The grantor also must provide a Form W-9 to trustee of trust.
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, 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 Pub. 5027, Identity Theft Information for
Taxpayers.
Victims of identity theft who are experiencing economic harm or a
systemic 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.
For this type of account:
Give name and SSN of:
1. Individual
The individual
2. Two or more individuals (joint
account) other than an account
maintained by an FFI
The actual owner of the account or, if
combined funds, the first individual on
the account
1
3. Two or more U.S. persons
(joint account maintained by an FFI)
Each holder of the account
4. Custodial account of a minor
(Uniform Gift to Minors Act)
The minor
2
5. 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
The grantor-trustee
1
The actual owner
1
6. Sole proprietorship or disregarded
entity owned by an individual
The owner
3
7. Grantor trust filing under Optional
Form 1099 Filing Method 1 (see
Regulations section 1.671-4(b)(2)(i)
(A))
The grantor*
For this type of account:
Give name and EIN of:
8. Disregarded entity not owned by an
individual
The owner
9. A valid trust, estate, or pension trust
Legal entity
4
10. Corporation or LLC electing
corporate status on Form 8832 or
Form 2553
The corporation
11. Association, club, religious,
charitable, educational, or other tax-
exempt organization
The organization
12. Partnership or multi-member LLC
The partnership
13. A broker or registered nominee
The broker or nominee
Page 6
Form W-9 (Rev. 10-2018)
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 phishing@irs.gov. You may also report misuse
of the IRS name, logo, or other IRS property to the Treasury Inspector
General for Tax Administration (TIGTA) at 1-800-366-4484. You can
forward suspicious emails to the Federal Trade Commission at
spam@uce.gov or report them at www.ftc.gov/complaint. You can
contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338).
If you have been the victim of identity theft, see www.IdentityTheft.gov
and Pub. 5027.
Visit www.irs.gov/IdentityTheft to learn more about identity theft and
how to reduce your risk.
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. commonwealths and 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.
Provider Web Portal (PWP) Registration
Complete the following steps to create your PWP user account.
4 Step Registration
1. New User? Register Now
Visit https://pwp.envolvedental.com and click the New User?
Register Now button.
2. Select Payee
On the Registration page, click the Payee Registration button.
3. Enter Information
On the Payee Registration page, enter all required information.
• Payee ID is listed on the Welcome Letter.
• Username cannot be the same as Payee Name.
• Password cannot be the User Name.
4. Create Account
After all information is entered correctly, click Create button to
create your PWP user account.*
*At initial login, you will be prompted to verify the email address provided. If you do
not receive your verification code within 5 minutes, please check your spam folder.
Envolve Benefit Options, Inc. does not exert economic pressure to persuade institutions to grant privileges that would not otherwise be granted
or pressure health care providers/institutions to render care beyond the scope of their training or experience.
STATEMENT OF INPATIENT ADMISSION COVERAGE
COMPLETION OF THIS FORM IS REQUIRED IF PROVIDER/GROUP DOES NOTE HAVE ADMITTING PRIVILEGES
Individual Providers (if this statement applies to more than one provider, do not list providers here):
Provider Name: _____________________________________ NPI:____________________________
Provider Groups (list provider names and NPIs below):
Practice Name: _____________________________________ Tax ID:__________________________
To be considered for panel participation with Envolve Dental, Inc. (Envolve Dental) an applicant that
does not have hospital staff privileges must refer patients to a provider with admitting privileges or a
participating facility.
I acknowledge that I have the responsibility to notify Envolve Dental of any hospital privilege change.
PREPARED BY (PRINT) DATE
SIGANATURE
Submit this form with credentialing or recredentialing materials to Envolve Dental’s Credentialing Department:
Fax Number: 844-847-9807
Email: dentalcredentialing@envolvehealth.com
Provider Groups: List provider names and National Provider Identifier (NPI) associated with this statement below.
Name: ____________________________________________ NPI:____________________________
Name: ____________________________________________ NPI:____________________________
Name: ____________________________________________ NPI:____________________________
Name: ____________________________________________ NPI:____________________________
Name: ____________________________________________ NPI:____________________________
Name: ____________________________________________ NPI:____________________________
Name: ____________________________________________ NPI:____________________________
Name: ____________________________________________ NPI:____________________________
Name: ____________________________________________ NPI:____________________________
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