Provisional Credentialing Attestation Form
In accordance with New York State Public Health Law, EmblemHealth allows provisional credentialing for
recently licensed or recently relocated health care practitioners joining a group practice, given certain
conditions.
Practitioner License Number: _________________________ Tax ID Number: ___________________________
In order to determine whether you are eligible for this designation, please answer the following questions:
1. Are you a newly licensed physician; Yes No
2. Are you a physician who has recently relocated to New York from another state and
has not previously practiced in New York; or Yes No
3. Are you a physician who has changed his/her corporate relationship in a way that results
in the issuance of a new tax identification number (TIN) under which the physician’s
services are billed and who previously had a participation contract with the insurer
immediately before the change?
Yes No
This application, including any certification and questionnaire we request that you complete, is not a
determination on your application. You will be notified of any such determination by separate correspondence.
Provisional Eligibility
Please be advised that eligibility for this provisional designation is based upon your responses above and your
confirmation that, should your application be denied, you or your group practice shall refund any payments
made by EmblemHealth for network services you provide, which exceed any out-of-network benefits payable
under a member’s contract with EmblemHealth. You or your group practice shall not pursue reimbursement
from members, except to collect the copayment or coinsurance that otherwise would be payable had a
member received services from a health care professional in EmblemHealth’s network.
Please note: Providers receiving provisional status cannot be designated for primary care.
Attestation
I,______________________________, on behalf of _________________________________, certify that:
(Print practitioner name) (Print group practice name)
I/group shall refund any payments made by EmblemHealth for in-network services I/group provide that
exceed any out-of-network benefits payable under a member’s contract with EmblemHealth. I/group
shall not pursue reimbursement from members, except to collect the copayment or coinsurance that
otherwise would have been payable had the member received services from a health care professional in
EmblemHealth’s network.
_____________________________________________________________ Date ____________________
(Practitioner signature)
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