View
3
Download
0
Category
Preview:
Citation preview
Heritage Summit HealthCare LLC Credentialing Review—Facility/Hospital page 1
HERITAGE SUMMIT HEALTHCARE LLC
Credentialing Review—Facility/Hospital Location/billing information Please copy this application to list additional office locations.
1. Facility name
Physical address
City State ZIP
County/Parish Phone ( ) Fax ( )
E-mail address Website (if applicable)
2. Is electronic billing available? .....................................................................................................................Yes or No
If yes, please list the electronic billing company or capability type (PDFs, scans, etc.)
What practice management system do you use?
3. Billing address _______________________________________________________________________ City State ZIP
County/Parish Phone ( ) Fax ( ) 4. Is this location a walk-in clinic? .................................................................................................................. Yes or No
If yes, please provide the hours of operation, including lunch times.
Monday _______ to _______ Thursday _______ to _______ Sunday _______ to _______
Tuesday _______ to_______ Friday _______ to _______ Please indicate lunch time:
Wednesday _______ to_______ Saturday _______ to _______ From _______ to _______
Administrative personnel
5. Administrator/CEO/CFO
Business office manager
Utilization review supervisor
Contract negotiator
Heritage Summit HealthCare LLC Credentialing Review—Facility/Hospital page 2
Facility
6. Is this facility corporate owned?.................................................................................................................. Yes or No
If yes, by whom?
7. If applicable, please complete the corporate ownership information below.
Name
Address
City State ZIP
County/Parish Phone ( ) Fax ( )
Contact person
E-mail address Website (if applicable)
8. Professional license number NPI
Medicare number Medicaid number
ASC license number FEIN
9. Name of professional liability carrier
Policy number
Amount of coverage Staff
10. Number of active physicians on staff Number of physicians on staff
Number of board-certified physicians Number of nurses on staff
11. Number of nurses on staff LPN ARNP RN CRNA
12. Are the credentials of all your staff verified prior to their employment or affiliation with your facility? .......... Yes or No Please attach a list of all staff physicians, their specialties and credentials.
Heritage Summit HealthCare LLC Credentialing Review—Facility/Hospital page 3
Accreditations
13. JCAHO accredited .................................................. Yes or No Date of last accreditation
Medicare approved.................................................. Yes or No Date of last inspection
CARF accredited (rehab hospital only) .................. Yes or No Date of last accreditation
Please enclose copies of your most recent accreditations.
14. Please attach current copies of the following:
Professional business license
Professional liability insurance coverage
W-9 (taxpayer identification number)
Alabama only—List of all ownership, financial or fiduciary interest facilities
During the contracting process, Heritage Summit HealthCare LLC reserves the right to utilize your facility/hospital services for workers’ compensation care.
___________________________________ ________________________ Applicant signature Date
( ) Print name and title of person completing this application Direct phone number
(For office use only)
Heritage Summit HealthCare LLC signature Date Facilities Only
Type of facility: Ambulatory surgery center Home health
Other (please define)
Note: All physicians will need to apply to and be accepted by Heritage Summit HealthCare LLC in order to provide network services.
Heritage Summit HealthCare LLC Credentialing Review—Facility/Hospital page 4
Hospitals Only
Type of hospital
Bed counts
Intensive care unit
Critical care unit
Progressive care unit
Medical
Surgical
Other (please define)
Orthopedic
Obstetrics/Gynecology
Skilled nursing
Pediatric
Please check which services are available in your hospital:
Physical therapy
Occupational therapy
Speech programs
CT scan
MRI
Home health
Does your hospital provide occupational medicine? Yes or No If yes, please list name(s) and address(es) below.
Name
Address
Does your hospital provide ambulatory surgery? Yes or No If yes, please list name(s) and address(es) below.
Name
Address
A photocopy of this document shall be as effective as the original. Please return form and attachments to our corporate office (address below).
ELEC SCM003 REV 03/14 (09-477)
HERITAGE SUMMIT HEALTHCARE LLC
CORPORATE OFFICE Florida PO Box 3623 • Lakeland, FL 33802-3623 • 863-665-6629 • 1-800-282-7644 • Fax 863-665-5177
SOUTHEAST REGION Georgia, Kentucky, North Carolina, South Carolina, Tennessee PO Box 600 • Gainesville, GA 30503-0600 • 678-450-5825 • 1-800-971-2667 • Fax 770-531-1349
SOUTHWEST REGION Alabama, Arkansas, Louisiana, Mississippi, Texas PO Box 80793 • Baton Rouge, LA 70898-0793 • 225-928-0820 • 1-888-468-2539 • Fax 225-926-1226
www.summitholdings.com
Recommended