Uniform Credentialing Application to Participate as a ...Copy of Curriculum Vitae or work history after graduation from Medical, Dental or other professional school. Cultural Competency

Managing Mental Health, Intellectual/Developmental Disabilities and Substance Abuse Services 910-673-9111 (FAX) 910-673-6202 www.sandhillscenter.org Victoria Whitt, CEO

P.O. Box 9, West End, NC 27376 24-Hour Access to Care Line: 800-256-2452

TTY: 1-866-518-6778 or 711 Serving Anson, Guilford, Harnett, Hoke, Lee, Montgomery,

Moore, Randolph & Richmond Counties

Uniform Credentialing Application to Participate as a Health Care Practitioner

For IPRS (State Funding) and Medicaid

Please submit application to:

Sandhills Center for MH, I/DD & SAS Network Operations Dept.

Credentialing Specialist P.O. Box 9

West End, NC 27376

Page 2 of 28 SHC Uniform LIP Credentialing Application qmcappd 03/26/2019

Instructions A Licensed Independent Practitioner must apply for and be credentialed as a practitioner with Sandhills Center to qualify for reimbursement of services provided to Sandhills Center members. Additionally, Practitioners must have a signed contract with Sandhills Center or be employed by an Organization or Group Practice that has a signed contract with Sandhills Center to qualify for reimbursement of services provided to Sandhills Center Members. ****Please Identify Areas of Clinical Expertise and Treatment by completing and signing the Practice Preference Data on the attached Cultural, Racial, Ethnic, Gender, and Linguistic Data Form.****

The credentialing process includes the following steps: 1. Provider completes and signs the Licensed Independent Practitioner Credentialing Application for

Medicaid and IPRS to Participate as a Health Care Practitioner and returns it along with the requiredcredentials to:

Sandhills Center for MH/I/DD/SAS Network Operations Department Attn: Credentialing Specialist

P.O. Box 9 West End, NC 27376

2. A credentialing Application to Participate as a Health Care Practitioner is considered to be invalid andmust be returned to the provider for correction and/or for additional information if:• The version date on any of the documents that comprise the provider Credentialing packet is prior to

March 2019. Older versions are not accepted. • All spaces in the application have not been completed. (Please indicate “N/A” or “None”, if the

question is not applicable). • The Signatures, where required, are not original and dated.

• The Signatures are not by the individual applicant.

• The text has been altered, highlighted, struck through, or obstructed through the use of correction fluids.

• The responses are illegible.

• The National Provider Identifier is not a valid number.

• Any of the documents or pages that comprise the credentialing Application to participate as a Heath Care Practitioner is missing.

• Any of the requested information in any of the documents that comprise the credentialing Application to participate as a Health Care Practitioner is missing, with the exception of the fax number.

Before submitting the credentialing Application, make sure you have completed the following: Include an answer in all spaces. Indicate “N/A” or “None”, if the question is not applicable. The practitioner for whom the credentialing application is being submitted has signed and dated all pages requiring signature within the application.


Before submitting the credentialing Application, make sure you have enclosed the following, if applicable:

Copy of the provider’s original state(s) license(s) and current registration. If provisionally licensed, submit a current copy of your supervision contract and complete the clinical supervisor information on Item 56 of Section 1 of application. Copy of current Federal DEA certificate (for MD/DOs, Physician Assistants and Psychiatric Nurse Practitioners). The Certificate must have a valid date and refer to current address. Copy of South Carolina Controlled Drug Substance Certificate and DEA information, if applicable. • Copy of the Certificate of Insurance for your current professional liability, with coverage amounts of

$1,000,000 / $3,000,0000 aggregate, effective date, expiration date, and policy number. (SandhillsCenter cannot accept Notice of Intent as proof of insurance).

• Completed, signed and dated, included Waiver regarding Auto Insurance Coverage form. LicensedPractitioners who certify in writing that they do not transport clients shall not be required to obtainAutomobile Liability Insurance.

• Licensed Practitioners who do not employ any staff shall not be required to obtain Worker’sCompensation or Employer’s Liability Insurance.

Copy of National Provider Identifier (NPI) Certification Letter for Agency and Clinician(s). Copy of certificate from the Specialty Board, if applicable. Physicians who are not “Board Certified” must provide an official certified copy of educational transcripts from highest level of education. Letter(s) of reference or recommendation, and/or oversight, if required (SHC Provider Evaluation Forms included in this packet). Minimum of two (2) references. Must be dated within the past 180 days. At least one of the references needs to come from a Peer-Licensed Practitioner (not partner), Supervisor, Chief of Department/Staff where practitioner has admitting privileges (not partner) and Referring Physician or Practitioner. SHC reserves the right to contact at least one (1) reference. Note: If provisionally licensed, one of the references must come from your clinical supervisor. Copy of Educational Commission of Foreign Medical Graduate Certificate-ECFMG, if applicable. Copy of Curriculum Vitae or work history after graduation from Medical, Dental or other professional school. Cultural Competency Training is required. Current Valid Enrollment with NCTracks to include all of the clinician’s service site address. Completed Acknowledgement and Authorization for Social Security Number Check form. For Solo Licensed Independent Practitioners only: Copy of W-9 Form. Sandhills Center will schedule a Health and Safety Review visit. Each provider facility must be accommodating for members with physical disabilities. If facility is not accommodating, please provide an explanation of how those members with physical disabilities would be accommodated. Original signed and dated SBI Authority for Release of Information form. Original signed and dated Trading Partner Agreement.


Examples of documentation to attach to this application.

Original N.C. License Medical Board Registration DEA Registration

Board Certification Certificate of Insurance


Section 1: Demographic and Personal Data:

Date of Application: Solo LIP? LIP w/agency?

1. Name of Applicant:

Last Name First Name Middle Name Maiden 2. List Current Credentials: 3. Date of Birth: 4. Place of Birth:5. Social Security Number: 6. Sex: Male Female 7. Type of Practice: 8. Specialty:

9. What population(s) do you treat (e.g., geriatric, all ages):

10. Language(s) Spoken, including sign language: 11. Are interpreters available: Yes No

12. Name of Practice: 13. Main/Billing Office Address: (If you maintain more than one office, list each office, address, and hours of operation.)

Address: Street City State Zip+4 (Required)

14. Check (√) County of Address: Anson Guilford Harnett

Hoke Lee Montgomery Moore Randolph Richmond

Other: 15. Phone #: 16. Fax #:17. Email: 18. Accepting New Patients: Yes No Restrictions: 19. Handicapped accessible: Yes No

If no, explain how you would accommodate members with physical disabilities:

20. Days/Hours of Operation Sunday Monday Tuesday Wednesday Thursday Friday Saturday

21. IRS requires reimbursement be made payable to name of practice affiliated with Federal Tax ID #:

Name: (if different from practice name): Billing Address: (if different from practice name): Address:

Street City State Zip+4 (Required) 22. Are you enrolled in NC Tracks? Yes No (If “No”, provide Enrollment Registration # and Submission Date)

Registration #: Submission Date: 23. Taxonomy #(s): List all applicable to your main billing office.

24. National Provider Identifier (NPI) #: (Attach copy of NPI Certification Letter to application)

25. DEA #: (Attach copy to application)

Exp. Date:


Section 1: Demographic and Personal Data (continued):

26. Administrative Contact:Name:Title: Address:

Street City State Zip+4 (Required) Phone #: Fax #: Email:

27. Name other provider(s) in your practice (if not enough space, please attach additional sheet):

28. Do nurse practitioners, physician assistants, midwives, social workers, or other non-physician providers provide care to patients in you practice? Yes No (If yes, please attach proof of professional liability insurance.)

29. Name and address of provider(s) who share call with you (if necessary, please attach additional sheet): Name: Name: Address: Address:

30. Specify the arrangements for 24 hour/7 day coverage apart from and in addition to Community Emergency Response Services (i.e. 911, Emergency Department, etc.):

31. Secondary Office Practice Name: Address:

Street City State Zip+4 (Required) 32. Check (√) County of Address:

Anson Guilford Harnett Hoke Lee Montgomery

Moore Randolph Richmond Other:

33. Federal Tax ID #: 34. Taxonomy #(s): List all applicable to your secondary office.

35. National Provider Identifier (NPI) #: 36. Phone #: 37. Fax #:38. Email: 39. Accepting New Patients: Yes No Restrictions: 40. Handicapped accessible: Yes No


41. Days/Hours of Operation Sunday Monday Tuesday Wednesday Thursday Friday Saturday


Section 1: Demographic and Personal Data (continued)

42. Additional Office Address:Practice Name: Address:

Street City State Zip+4 (Required) 43. Check (√) County of Address:

Anson Guilford Harnett Hoke Lee Montgomery

Moore Randolph Richmond Other:

44. Federal Tax ID #: 45. Taxonomy #(s): List all applicable to your additional office.

46. National Provider Identifier (NPI) #: 47. Phone #: 48. Fax #:49. Email: 50. Accepting New Patients: Yes No Restrictions: 51. Handicapped accessible: Yes No


52. Day/Hours of Operations: Sunday Monday Tuesday Wednesday Thursday Friday Saturday

53. Are you currently providing services at another agency (if so, please list the name of the agency): Agency Name: Start Date: Agency Name: Start Date: Agency Name: Start Date: Agency Name: Start Date:

54. Provide the following information for each state in which you are currently or were previously licensed to practice (if necessary, please attach additional sheet):

State Date of License License Number

License Type

Status: Active, Inactive, Suspended

Expiration Date

****PLEASE ATTACH A COPY OF EACH STATE LICENSE CERTIFICATE**** Complete only if Licensed in South Carolina

55. SC Controlled Drug Substance Certificate:(Attach copy to application)

Expiration Date:

56. If provisionally licensed, provide a copy of your current supervision contract and the name and contact information for your clinical supervisor: Clinical Supervisor: Address:

Street City State Zip+4 (Required) Phone #: Email:


Section 1: Demographic and Personal Data (continued):

57. Certification of Specialty Boards as applicable:a) If you are certified by a specialty board, indicate name of board and date of certificate.

Primary Specialty Board: Date Certified Expiration Date

Secondary Specialty Board: Date Certified Expiration Date

b) Are you listed in the American Board of Medical Specialists? Yes No c) If you have applied to a specialty board for examination, give the name of board and the date of the

scheduled examination.Specialty Board Name: Date:

d) If you have not applied to a specialty board, please explain:

58. List the dates of all current professional memberships in societies, including state and county societies:Professional Membership From (Month/Year) To (Month/Year)

59. List all hospitals where you currently have privileges and indicate the type and status of those privileges:a) Hospital: Estimated % of Admissions:

Privilege and Status of Privilege: b) Type: Active Admitting Associate Consulting Courtesy c) Status: Pending Provisional Suspended Temporary Visiting d) Primary Admitting Facility: Estimated % of Admissions:

e) Type: Active Admitting Associate Consulting Courtesy f) Status: Pending Provisional Suspended Temporary Visiting

60. If you do not have admitting privileges, who admits for you: (Please attach a copy of your Admitting Plan)Name of Admitting Individual: Address:

Street City State Zip+4 (Required) Phone #: Email:


Section 2: Education Practice History

1. Medical, Dental or other Professional School Attended: (“See Resume” is not acceptable.)Institution: Address: City: State: Zip: Degree: Date From: Date To: Name as it appears on degree: Please attach Educational Commission of Foreign Medical Graduate Certificate – (ECFMG) if applicable. 2. Internship:Institution: Address: City: State: Zip: Specialty: Date From: Date To: 3. Residency:Institution: Address: City: State: Zip: Specialty: Date From: Date To: 4. Other Residency/Fellowship – (specify)Institution: Address: City: State: Zip: Specialty: Date From: Date To: 5. List work history since beginning of medical, dental or other professional school (last five [5] years) and

explain any employment gaps longer than 6 months; please be specific. “See Resume” is not acceptable. (Ifnot enough space, please attach additional sheet).

Practice Name: From - Month/Year To - Month/Year Current Practice: Current Practice: Current Practice: Previous Practice: Previous Practice: Previous Practice: Previous Practice: 6. List other training and/or education (including CME) within the last five (5) years:

7. Have you involuntarily or voluntarily withdrawn, or been suspended from any internship, residencyor fellowship training program (Please explain):

8. Please explain any incident(s) in which you have involuntarily or voluntarily withdrawn your application forappointment, clinical privileges or reappointment before a decision was made by a hospital or healthcarefacility’s governing board:


Section 3: Professional Information

Please check (√) yes or no for the following questions. Please complete the attached Supplemental Form for any questions to which you answer “yes”. Also, please sign and date this application. If this application does not have the provider’s signature, it cannot be accepted. 1. Has your license to practice in any jurisdiction ever been limited, restricted, reduced, suspended,

voluntarily surrendered, revoked, denied or not renewed; have you ever been reprimanded by astate licensing agency; or are any of these actions pending with respect to your license; are youunder investigation by any licensing or regulatory agency?(If yes, please complete Supplemental Question #1.)

Yes No

2. Has your professional employment or membership in a professional organization ever been subjectto disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed,or voluntarily relinquished during or under threat of termination for any reason?(If yes, please complete Supplemental Question #2.)

Yes No

3. Has your Drug Enforcement Agency registration or other controlled substance authorization everbeen limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarilysurrendered or limited your registration during or under the threat of an investigation or any suchactions pending?(If yes, please complete Supplemental Question #3.)

Yes No

4. Have you ever been sanctioned or suspended by Medicare or Medicaid?(If yes, please complete Supplemental Question #4.) Yes No

5. To your knowledge, have you ever been reported to the National Practitioner Data Bank or theNorth/South Carolina Board of Medical Examiners?(If yes, please complete Supplemental Question #5.)

Yes No

6. Have you ever been convicted of a felony or misdemeanor, or are you under investigation withrespect to such conduct?(If yes, please complete Supplemental Question #6.)

Yes No

7. Has a professional liability claim been assessed against you in the past five years, or are there anyprofessional liability cases pending against you?(If yes, please complete Supplemental Question #7.)

Yes No

8. Has any liability insurance carrier cancelled, refused coverage, or rated up because of unusual riskor have any procedures been excluded from your coverage?(If yes, please complete Supplemental Question #8.)

Yes No

9. Have you ever practiced without liability coverage?(If yes, please complete Supplemental Question #9.) Yes No

10. Do you currently have any medical, chemical dependency or psychiatric conditions that mightadversely affect your ability to practice medicine or surgery or to perform the essential functionsof your position without reasonable accommodation?(If yes, please complete Supplemental Question #10.)

Yes No

11. Have your Hospital and/or Clinic privileges ever been limited, restricted, reduced, suspended,revoked, denied, not renewed, or have you voluntarily surrendered or limited your privilegesduring or under the threat of an investigation or are any such actions pending?(If yes, please complete Supplemental Question #11.)

Yes No

Signature Date

***Please provide additional detailed information on the following Supplemental Form.

Page 11 of 28 SHC Uniform LIP Re-Credentialing Application qmcappd 03/26/2019

Supplemental Form

All spaces in the application must be completed. (Please indicate “N/A” or “None”, if the question is not applicable)

Applicant Name: SHC Provider ID #:

1. License Limited, Reprimanded, etc.:List State(s) where action took place: Date(s) license revoked, suspended, etc.: From To Please explain: 2. Employment/Membership Suspended, Limited, etc.:List State(s) where action took place: Date(s) license revoked, suspended, etc.: From To Please explain: 3. Drug Enforcement Agency (DEA) ExplanationList State(s) where action took place: Date(s) license revoked, suspended, etc.: From To Please explain: 4. Medicare/Medicaid Sanction Disciplinary Action(s)Disciplined Action(s): List State(s) where action took place: Date(s) of Action: From To Please explain: 5. National Practitioner Data Dank Report(s)Please explain the NPDB report (if you have a copy please attach): 6. Felony or MisdemeanorDid you serve a sentence: Yes No If Yes, please check (√) how many years. 1 2 3 4 5 6 Other: Please explain charge and verdict: List State(s): 7. Named in Professional Liability Judgment, Settlement, etc.Please explain, include dates & amounts: 8. Cancelled Refused Coverage, etc.Please list Insurance Carrier(s): Please explain: 9. Practiced Without Liability CoveragePlease explain: 10. Medical, Chemical Dependency, or Psychiatric ConditionsPlease explain: 11. Hospital or Clinic Privileges Revoked, Restricted, etc.List Hospital(s): Date privileges revoked, suspended, etc.: From To Please explain:


Section 4: Ownership Information

1. Do you have ownership or control interest of 5% or more in thisorganization? Yes No

2. List all partners, managing employees and Electronic Funds Transfer (EFT) authorized individualsassociated with your practice, and provide the information requested on each.

Name: Address: Title: SSN: License #: Date of birth: % Owner: Check business relationship that applies:

Owner Shareholder Partner Manager EFT Auth Staff Check relationship to enrolling provider (if applicable).

Spouse Parent Child Sibling


Owner Shareholder Partner Manager EFT Auth. Staff Check relationship to enrolling provider (if applicable).



Owner Shareholder Partner Manager EFT Auth. Staff Check relationship to enrolling provider (if applicable).



Owner Shareholder Partner Manager EFT Auth Staff Check relationship to enrolling provider (if applicable).



Section 4: Ownership Information (continued)

3. Do you have ownership or control interest of 5% or more in other organizationsthat bills Medicaid for services?

Yes No

If yes, please fill in the following for each organization:

Organization Legal Business Name: Employer ID #: National Provider Identifier (NPI) #:






Sandhills Center Network Operations

Credentialing Specialist P.O. Box 9, West End, NC 27376

Fax: (910) 673-7013

Provider Evaluation Form Peer

(Licensed Practitioner, not partner) Referring Physician or Practitioner Supervisor

Chief of Department/Staff where practitioner has admitting privileges (Not partner) Name of the Applicant: Group Name:

The above provider is a Sandhills Center network applicant. Please provide us with information concerning His/Her professional qualifications. All information submitted will be held in strict confidence.

1. What is your specialty/credentials:2. What is your relationship to the applicant:3. How long have you known the applicant:4. How would you rate the applicant’s professional abilities:

Excellent Very Good Good Fair Poor 5. How would you rate the applicant’s ability to work and communicate with physician and

non physician staff: Excellent Very Good Good Fair Poor

6. How would you rate the applicant’s rapport with members: Excellent Very Good Good Fair Poor

7. What do you believe to be the applicant’s strenghts and weaknesses (if any) :a). Strengths:

b). Weaknesses:

8. To your knowledge, has the applicant had any of the following: Malpractice claim(s): Yes No Problems with medical licensure, certification or licensing boards: Yes No Revocation, denial or change in hospital privileges: Yes No History of/or current impairment due to drugs and/or alcohol: Yes No

***If your answer is yes to any of the above questions, please provide details.*** 9. Would you recommend this person as a provider for the Sandhills Center network:

Without reservation With reservation Would not recommend 10. Please provide any other information that would be helpful to us in evaluating this applicant:

Evaluator’s Signature Evaluator’s Printed Name Date Group Name: Address:

Street City State Zip Phone #: Email:


Sandhills Center Network Operations

Credentialing Specialist P.O. Box 9, West End, NC 27376

Fax: (910) 673-7013

Provider Evaluation Form Peer

(Licensed Practitioner, not partner) Referring Physician or Practitioner Supervisor

Chief of Department/Staff where practitioner has admitting privileges (Not partner) Name of the Applicant: Group Name:

The above provider is a Sandhills Center network applicant. Please provide us with information concerning His/Her professional qualifications. All information submitted will be held in strict confidence.

1. What is your specialty/credentials:2. What is your relationship to the applicant:3. How long have you known the applicant:4. How would you rate the applicant’s professional abilities:

Excellent Very Good Good Fair Poor 5. How would you rate the applicant’s ability to work and communicate with physician and

non physician staff: Excellent Very Good Good Fair Poor

6. How would you rate the applicant’s rapport with members: Excellent Very Good Good Fair Poor

7. What do you believe to be the applicant’s strenghts and weaknesses (if any) :a). Strengths:

b). Weaknesses:

8. To your knowledge, has the applicant had any of the following: Malpractice claim(s): Yes No

Problems with medical licensure, certification or licensing boards: Yes No Revocation, denial or change in hospital privileges: Yes No History of/or current impairment due to drugs and/or alcohol: Yes No

***If your answer is yes to any of the above questions, please provide details.*** 9. Would you recommend this person as a provider for the Sandhills Center network:

Without reservation With reservation Would not recommend 10. Please provide any other information that would be helpful to us in evaluating this applicant:

Evaluator’s Signature Evaluator’s Printed Name Date Group Name: Address:

Street City State Zip Phone #: Email:


SANDHILLS CENTER

Licensed Independent Practitioners

Cultural, Racial, Ethnic, Gender, and Linguistic Data Form (This information will reside within Sandhills Center’s Provider Directory and the online Provider Search.

This section is self-reported information and requires no backup documentation)

By providing the information below, you will be assisting Sandhills Center with member/provider matching as well as providing information necessary for analyzing our Network and its ability to meet our Members cultural, racial, ethnic and linguistic needs.

Name of Practitioner: Name of Practice: Email Address: Counties Served:

Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Other:

Provider Type: APPCNS (Advanced Practice Psychiatric Clinical Nurse Specialist) DO LCAS LCSW LMFT LPA LPC PA PhD PsyD MD/NP

Psychiatric Other (please specify):

Priority Populations: MH – Adult SA – Adult I/DD - Adult MH – Child SA – Child I/DD - Child

Your Gender: Female Male

Your Race and/or Ethnicity (please check (√) all appropriate categories): White Black or African American American Indian and Alaska Native Asian, Pacific Islander Hispanic or Latino Other:

Populations(s) that you serve (please check (√) all that apply): Early Childhood (0-4) Child & Adolescent (5-21) Adult (22+)

Geriatrics (55+) Women Gay & Lesbian HIV/Aids Hearing Impaired Men

Gender Identity Issues Sexually Reactive/Aggressive Youth Visually Impaired Other:


Cultural, Racial, Ethnic, Gender, and Linguistic Data Form (continued) (This information will reside within Sandhills Center’s Provider Directory and the online Provider Search)

Culturally diverse populations that you feel competent to treat (please check (√) all that apply): White Black or African American American Indian and Alaska Native Asian, Pacific Islander Hispanic or Latino Other:

Practice Preference Data Language(s) you are able to communicate in fluently (please check (√) all that apply): American Sign Language English French

German Hmong Portuguese Russian Spanish Telugu

Other: (The sections below must have backup documentation to be listed with Sandhills Center)

Focus of Treatments You Provide (please check (√) all that apply): Amnestic Disorder Factitious Disorders Anxiety/Phobias Impulse Control Attention Deficit Hyperactivity Disorder Intellectual /Developmental Disabilities Autism – Asperger Obsessive-Compulsive Disorder Bipolar Disorder (manic-depressive illness) Personality Disorders Chemical Dependency/Substance Abuse Post Traumatic Stress Disorder Conduct Disorder Schizophrenia and other Psychotic Disorders

Co-Occurring/Dual DX-Mental Illness, Mental Health, Substance Abuse

Sexual & Gender Identity Disorders Illness, Mental Health/Substance Abuse

Dementia Disorder Sleep Disorders Depression Somatoform Disorders Eating Disorders Clinician Expertise/Certified Specialties (please check (√) all that apply):

Psychological Testing Therapy/Service Type Trauma Focused Cognitive/IQ Anger Management Abuse-Physical, Sexual, and/or

Emotional Developmental limited/extended Assessment Evaluation Maltreatment Forensic Screening/Evaluation Care/Vocational Counseling Neglect Neuro Psych Cognitive Behavioral Therapy Rape Personality Crisis/Solution focused Brief Therapy

Dialectial Behavior Therapy Faith Based Counseling General Psychiatry General Psychology Gero Psychiatry Grief and Loss Therapy Health Psychology –

Chronic Medical Conditions Marriage and Family Counseling Play Therapy, Filial Relaxation/

Meditation-Hypnotherapy Self-Direction

Yes No Completed Cultural Competency Training.


Practice Preference Data

Clinician Expertise/Certified Specialties that Require Verification (please check (√) all that apply):

Verification of specific expertise(s) and/or training(s) selected below must accompany this form for Sandhills Center recognition, i.e. training certificates, certification, supervisor letters verifying training, or proof of experience. If standard training for clinician’s licensure does not include area of identified expertise, additional documentation to support expertise will be required, e.g. a Psychiatrist who does psychological testing. Addiction Psychiatry (Fellowship in addiction Psychiatry/Board Certification/ASAM Certification/Experience) Eye Movement Desensitization and Reprocessing Therapy (Training Certificate/Experience) Addiction Treatment (LCAS/CAS/CCS/Experience) Forensic Psychology/Psychiatry (Fellowship in Forensic Psychiatry/Board Certification/Training/Experience) Child Psychiatry (Fellowship in child Psychiatry/Board Certification/Training/Experience) Trauma Focused Cognitive Behavioral (Course Completion at MUSC, Duke or NCTSN) Dialectical Behavior Therapy (Certification, Supervision, and Experience) Neuro Psych Assessment (Training, Supervision, and Experience)

Services Provided in Office: Yes No

Services Provided in the Community: Yes No Thank you for taking the time to submit this form. If this form is not completed and returned, your provider

information will not appear within the Sandhills Center online Provider Search or Provider Handbook.

To the best of my knowledge, I am able to meet all requirements necessary to apply for Sandhills Center Re-Credentialing for Licensed Independent Practitioner. I am submitting the attached Sandhills Center Licensed Independent Practitioner Credentialing Application, which, to my knowledge, is a true and complete representation of the required materials.

Signature of Licensed Independent Practitioner Date

Printed Name


Outpatient Behavioral Health Service Codes for IPRS & Medicaid

Please check (√) all that apply

Procedure Code Description

Available to Benefit Plan State (IPRS) Medicaid

90785 Interactive Complexity Add On State Medicaid 90791 Psychiatric Diagnostic Evaluation State Medicaid 90792 Psychiatric Diagnostic Evaluation with Medical Services State Medicaid 90832 Psychotherapy 30 Minutes State Medicaid 90833 Psychotherapy 30 Minutes Add On State Medicaid 90834 Psychotherapy 45 Minutes State Medicaid 90836 Psychotherapy 45 Minutes Add On State Medicaid 90837 Psychotherapy 60 Minutes State Medicaid 90838 Psychotherapy 60 Minutes Add On State Medicaid 90839 Crisis Psychotherapy first 60 Minutes State Medicaid 90840 Crisis Add For Each Additional 30 Minutes State Medicaid 90845 Psychoanalysis N/A Medicaid 90846 Family therapy w/o Patient State Medicaid 90847 Family therapy with Patient State Medicaid 90849 Group Therapy (Multiple Family) State Medicaid 90853 Group Therapy (Non-Multi- Family) State Medicaid 96110 Developmental Testing Limited State Medicaid 96112 Developmental Test Administration State Medicaid 96113 Dev Test Admin Addtl 30 State Medicaid 96116 Neurobehavioral Status Exam State Medicaid 96121 Neuro Exam Addtl hour State Medicaid 96130 Psych Test Eval 1st hour State Medicaid 96131 Psych Test Add on State Medicaid 96132 Neuropsych Test Eval State Medicaid 96133 Neuropsych Test add on State Medicaid 96136 Psych or Neuro tests two or more State Medicaid 96137 Psych test two or more add on State Medicaid 96138 Psych test Tech two or more NA Medicaid 96139 Psych test Tech two or more add on NA Medicaid 96146 Psych test Automated NA Medicaid


IPRS (State) Funds Only for Services for Non-Licensed Substance Abuse Professionals

Please check (√) all that apply

Evaluation & Management Codes

Evaluation & Management Codes are only provided by Physicians Assistants, Cert. Nurse Practitioners and Physicians

Check (√)

Procedure Code Description Check

(√) Procedure

Code Description

90865 Narcosynthesis for Psychiatric Diagnostic and Therapeutic Purposes 99220 Hospital Initial Observation Care High

Complexity

95970 Electronic Analysis of Implanted Neurostimulator 99221 Hospital Initial Care MD (30 min.)

95971 Electronic Analysis of Implanted Neurostimulator Simple Spinal Cord 99222 Hospital Initial Care MD (50 min.)

95972 Electronic Analysis of Implanted Neurostimulator Complex Spinal Cord (1hr.)

99223 Hospital Initial Care MD (70 min.)

95973 Electronic Analysis of Implanted Neurostimulator Complex Spinal Cord (30 min.)

99231 Hospital Subsequent Hospital Care MD Low Complexity (15 min.)

95974 Electronic Analysis of Implanted Neurostimulator Complex Cranial (1 hr.)

99232 Hospital Subsequent Hospital Care MD Moderate Complexity (25 min.)

95975 Electronic Analysis of Implanted Neurostimulator Complex Cranial (30 min.)

99233 Hospital Subsequent Hospital Care MD High Complexity (35 min.)

95978 Electronic Analysis of Implanted Neurostimulator 99234 Hospital Observation/Inpatient Care

Low Complexity

95979 Electronic Analysis of Implanted Neurostimulator (30 min.) 99235 Hospital Observation/Inpatient Care

Moderate Complexity

96125 Standardized Cognitive Performance Testing 99236 Observation/Inpatient Care High Complexity

96150 Physical Health and Behavior Assessment F-T-F (15 min.) 99238 Hospital Discharge Services (<30 min.)

95151 Physical Health and Behavior Reassessment 99239 Hospital Discharge Services (>30 min.)

96372 Therapeutic, Prophylactic, or Diagnostic Injection Intra-Muscular

99241 Outpatient Consultation MD Minor (15 min.)

96373 Therapeutic, Prophylactic, or Diagnostic Injection Intra-Arterial 99242 Outpatient Consultation MD Moderate

(30 min.)

96374 Therapeutic, Prophylactic, or Diagnostic Injection Intravenous Push 99243 Outpatient Consultation MD Severe

(40 min.)

96375 Therapeutic, Prophylactic, or Diagnostic Injection Subsequent Intravenous Push 99244 Outpatient Consultation MD Severe

(60 min.)

Check (√)

Procedure Code Description

YP830 Behavioral health Assessment YP831 Behavioral health Counseling and Therapy YP832 DMH Outpatient Treatment Group YP833 DMH Outpatient Tx Family Therapy w/ Client YP834 DMH Outpatient Tx Family Therapy w/o Client YP835 Alcohol and/or Drug Services; Group Counseling by Clinician


Evaluation & Management Codes (continued)

Evaluation & Management Codes are only provided by Physicians Assistants, Cert. Nurse Practitioners and Physicians

Check (√)

Procedure Code Description Check

(√) Procedure

Code Description

99201 Outpatient E&M New Patient F-T-F (10 min.) 99245 Outpatient Consultation MD Severe

(80 min.)

99202 Outpatient E&M New Patient F-T-F (20 min.) 99251 Inpatient Consultation MD Minor (20 min.)

99203 Outpatient E&M New Patient F-T-F (30 min.) 99252 Inpatient Consultation MD Low Severity

(40 min.)

99204 Outpatient E&M New Patient F-T-F (45 min.) 99253 Inpatient Consultation MD Moderate (55 min.)

99205 Outpatient E&M New Patient F-T-F (60 min.) 99254 Inpatient Consultation MD Moderate –

High Severity (80 min.)

99211 E & M Estab. Patient, w/wo MD (approx.5 min.) 99255 Inpatient Consultation MD Moderate –

High Severity (110 min.) 99212 Outpatient Visit Estab. Minor (10 min.) 99281 ER Visit, Minor 99213 Outpatient Visit Estab. Moderate (15 min.) 99282 ER Visit, Low Severity 99214 Outpatient Visit Estab. Severe (25 min.) 99283 ER Visit, Moderate Severity 99215 Outpatient Visit Estab. Severe (40 min.) 99284 ER Visit, High Severity

99217 Hospital Observation Care - Discharge 99285 ER Visit for the evaluation and management of a patient

99218 Hospital Initial Observation Care Low Complexity 99304 Initial Nursing Facility Care E&M

Low Complexity (25 min.)

99219 Hospital initial Observation Care Moderate Complexity 99305 Initial Nursing Facility Care E&M Moderate

Complexity (35 min.)

99306 Initial Nursing Facility Care E&M high Complexity (45 min.) 99337 Estab. Patient Domiciliary/Rest Home E&M

Moderate to High Severity (60 min.)

99307 Subsequent Nursing facility Care E&M Review of Case (10 min.) 99341 New Patient Home Visit E&M Low Severity

(20 min.)

99308 Subsequent Nursing Facility Care E&M Low Complexity (15 min.) 99342 New Patient Home Visit E&M Low


99309 Subsequent Nursing Facility Care E&M Moderate Complexity (25 min.) 99343 New Patient Home Visit E&M Low Moderate


99310 Subsequent Nursing Facility Care E&M High Complexity (35 min.) 99344 New Patient Home Visit E&M High Severity

(60 min.)

99315 Nursing Facility Discharge Management (<30 min.) 99345 New Patient Home Visit E&M High


99316 Nursing Facility Discharge Management (>30 min.) 99347 Estab. Patient Home Visit E&M (15 min.)

99318 Nursing Facility, E&M Low to Moderate Complexity (30 min.) 99348 Estab. Patient Home Visit E&M Low


99324 New Patient Domiciliary/Rest Home E&M Low Severity (20 min.) 99349 Estab. Patient Home Visit E&M Moderate


99325 New Patient Domiciliary/Rest Home E&M Low Complexity (30 min.) 99350 Estab. Patient Home Visit E M High


99326 New Patient Domiciliary/Rest Home E M Moderate Complexity (45 min.) 99354 Prolonged MD Service w/F-T-F Patient Contact

in Office (60 min.)

99327 New Patient Domiciliary/Rest Home E&M High Severity (60 min.) 99355 Prolonged MD Service w/F-T-F Patient Contact

in Office (30 min.)

99328 New patient Domiciliary/Rest Home E&M High Complexity (75 min.) 99356 Prolonged MD Service w/F-T-F Patient Contact

Inpatient (60 min.)

99334 Estab. Patient Domiciliary/Rest Home E&M (15 min.) 99357 Prolonged MD Service w/F-T-F Patient Contact

Inpatient (30 min.)

99335 Estab. Patient Domiciliary/Rest Home E&M Low Complexity (25 min.) Q3014GT TelePsych Site Facility Fee

99336 Estab. Patient Domiciliary/Rest Home E&M Moderate Complexity (40 min.)

Managing Mental Health, Intellectual/Developmental Disabilities and Substance Abuse Services 910-673-9111 (FAX) 910-673-6202 www.sandhillscenter.org Victoria Whitt, CE


TTY 1-866-518-6778 or 711 Serving Anson, Guilford, Harnett, Hoke, Lee, Montgomery,


Attestation Statement Important: Submit Original only

No Stamps or Copies Please

This Application is to be signed by the individual provider/clinician applying for Credentialing.

All information submitted by me in this application, as well as any attachments or supplemental information, is true, current, and complete to my best knowledge and belief as of the date of signature below. I fully understand that any significant misstatement in this application may constitute cause for denial of my application or termination of a resulting participation agreement.

By application for membership in the Sandhills Center Network, I signify my willingness to appear for interview in regard to my application. I authorize Sandhills Center to consult with administrators and members of the medical staffs of hospitals or institutions with which I have been associated and with others, including past and present malpractice carriers, who may have information bearing on the questions in this application. Upon request, I will obtain and provide to Sandhills Center materials pertaining to my qualifications and competence, including, materials relating to complaints filed, any disciplinary action, suspension, or action to curtail my medical-surgical privileges. I further consent to the inspection by representatives of Sandhills Center of all documents that may be material to an evaluation of my professional qualifications and competence.

I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubt about such qualifications. I release from liability all representatives of Sandhills Center for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I release from any liability, all individuals and organizations that provide information to Sandhills Center in good faith and without malice concerning this application and I hereby consent to the release and verification of information relating to any disciplinary action, suspension, or curtailment of medical-surgical privileges to Sandhills Center.

I understand that if my application is rejected for reasons relating to my professional conduct or competence, Sandhills Center, may report the rejection to the appropriate state licensing board and/or National Practitioner Data Bank.

In the event I am accepted for participation in Sandhills Center, I hereby consent to Sandhills Center for inspection of my patient records relating to Sandhills Center members as necessary for its peer and utilization review purposed as permitted by state or federal law and regulation I further agree to notify Sandhills Center in a timely manner (not to exceed 30 days) of any changes to the information requested on the initial application.

Signature of Applicant Date

Printed Name of Applicant Title

If this application does not have the provider’s signature, it cannot be accepted. (Please sign and date this Attestation Statement).





Trading Partner Agreement TRADING PARTNER AGREEMENT– Electronic Data Interchange (EDI)

This document constitutes an agreement to the following provisions for exchanging Electronic Data Interchange (EDI) between the Trading Partner and Sandhills Center (SHC).

The Trading Partner agrees:

1. To conform to the requirements for Administrative Simplifications as defined in the provisions of the HealthInsurance Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-91), and regulations promulgated there underand to take no action which adversely affects SHC’s HIPAA compliance.

2. That it will promptly notify SHC of any and all unlawful or unauthorized disclosures of confidential information orprotected health information (PHI) that comes to its attention and will cooperate with SHC in the event any litigationarises concerning the unauthorized use, transfer, or disclosure of either confidential or protected health information.

3. That it will use sufficient security procedures to ensure that all transmissions of documents are authorized andprotect all participant-specific data from improper access.

4. That it will ensure that all files transmitted comply with the appropriate national Electronic Data Interchange (EDI)Transaction Set Implementation Guide, in effect on the date of transmission, as provided by the Health InsurancePortability and Accountability Act (HIPAA) of 1996.

5. That it will establish and maintain procedures and controls so that information concerning SHC health planparticipants or any information obtained from SHC, shall not be used by agents, officers, or employees of the tradingpartner other than for its sole intended purpose.

6. That the information stated in any EDI Trading Partner Profile(s) submitted with this Agreement, or subsequently iscorrect and complete.

7. That it will allow SHC 30 days after receipt of written notice from the Trading Partner if there is any change in thetrading partner representative or location where electronic transactions are sent.

8. That it is bound by this written agreement to comply with state and federal law, if the trading partner is anintermediary for the billing provider.

SHC agrees:

1. To conform to the requirements for Administrative Simplifications as defined in the provisions of the HealthInsurance Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-91), and regulations promulgated there underand to take no action which adversely affects the trading partner’s HIPAA compliance.

2. That it will use sufficient security procedures to ensure that all transmissions of documents are authorized andprotect all participant-specific data from improper access.

3. That it will ensure that all files transmitted comply with the appropriate national Electronic Data Interchange (EDI)Transaction Set Implementation Guide, in effect on the date of transmission, as provided by the Health InsurancePortability and Accountability Act (HIPAA) of 1996.

Both parties agree:

1. That documents will not be considered as received and no responsibility assigned until accessible at the receivingparty’s computer.

2. That upon receiving any documents, to prepare and transmit a timely response or an acknowledgement of transactionreceipt. If acceptance of a document is required, a document is not considered received until an acceptanceacknowledgement is returned.

3. To notify the other party within a reasonable time frame if any transmitted data are received in an unintelligible orgarbled form.

4. That each party will provide and maintain the equipment, software, services, and testing necessary to transmit andreceive documents.

5. To conduct business and perform as required by this agreement and any applicable rules or regulations.

6. That this agreement will remain in effect until terminated by either party with at least 30 days prior written notice.The notice will specify the effective date of termination, but will not affect the obligations or rights of either partyprior to the effective date of termination. This agreement is automatically terminated in the event the tradingpartner is disqualified through a federal administrative action or state action. That any document transmittedaccording to this agreement will be considered an original and signed when received.

Effect of Termination

1. Except as provided in paragraph (2) of this section or in the contract or by other applicable law or agreements, upontermination of this agreement and services provided by the Trading Partner, for any reason, the Trading Partner shallreturn or destroy all Protected Health Information received from SHC, or created or received by Trading Partner onbehalf of SHC. This provision shall apply to Protected Health Information that is in the possession of subcontractorsor agents of the Trading Partner. Trading Partner shall retain no copies of the Protected Health Information.

2. In the event that Trading Partner determines that returning or destroying the electronic protected health informationis not feasible, Trading Partner shall provide to SHC notification of the conditions that make return or destructionnot feasible. Trading Partner shall extend the protections of this agreement to such Protected Health Informationand limit further uses and disclosures of such Protected Health Information to those purposes that make the returnor destruction infeasible, for so long as Trading Partner maintains such Protected Health Information.

Trading Partner Name

Street Address Line 1 (Site/Physical Address, not a P.O. Box)

Street Address Line 2

City, State, Zip Code

Contact Information (Phone Number, email address)

____________________________________________________________________________________ Signature of Applicant or Authorized Individual Date

____________________________________________________________________________________ Printed Name and Title

___________________________________________________________________________________

For Sandhills Center for MH, DD & SAS use only

Trading Partner’s EDI Submitter ID: Sandhills Center for MH, DD & SAS Receiver ID: SHC303

Please return completed form to: Sandhills Center for MH, DD & SAS P.O. Box 9 West End, NC 27376 Attn: EDI Coordinator, Information Technology Department

AUTHORITY FOR RELEASE OF INFORMATION State Access Only

Name Check Access I authorize the North Carolina Department of Justice through the State Bureau of Investigation to perform a North Carolina name-based criminal history record information check in connection with my application for employment, my employment or volunteer services with SANDHILLS CENTER FOR MENTAL HEALTH pursuant to DHHS-LONG TERM – STATE AND FED – NCGS 122C-80B/131 D-40A A1/131D-40A A1.

(type or print clearly)

Last Name First Middle Maiden

Social Security # Date of Birth Sex Race

I understand that the North Carolina State Bureau of Investigation, officials and employees shall not be held legally accountable in any way for providing this information to the above named agency, and I hereby release said agency and persons from any and all liability which may be incurred as a result of furnishing such information. I further understand that the above named agency cannot provide a HARD COPY of the results of this criminal history record check to me.

*Disclosure of social security number is entirely voluntary and not required. If disclosed, the social securitynumber will be utilized to assist with accurate identification/exclusion of possible criminal history records.

Applicant’s/Employee’s/Volunteer’s Signature

____________________________________

Date _____________________________________

This form must be maintained on file with the above named agency for one year. UPON COMPLETION OF THIS FORM, MAIL A PHOTOCOPY TO THE ADDRESS INDICATED BELOW:

State Bureau of Investigation Criminal Information and Identification Section Attn: Applicant Unit Post Office Box 29500 Raleigh, North Carolina 27626-0500 ORI # HCP000008 – SANDHILLS CENTER FOR MENTAL HEALTH

HCP000008





__________________________________________________________________________________________

WAIVER REGARDING AUTO INSURANCE COVERAGE

Dear Provider:

Sandhills Center is now requiring that all applicants provide proof of auto insurance coverage or sign a waiver stating that the auto insurance is not required as the applicant will not be transporting consumers. If you will not be transporting consumers, we ask that you please complete, sign and date the waiver below as part of your Sandhills Center application.

I, __________________________________________, attest to one of the following: Please Print Name

I will be transporting patients and have attached proof of auto insurance coverage.

I will not be transporting patients under any circumstances, and am therefore, not required to provide proof of auto insurance coverage. I hereby acknowledge that by checking this option, Sandhills Center is reasonably relying upon this representation in making a decision on my credentialing application.

_______________________________________________________________________________________________ Name of Agency or Practice

_______________________________________________________________ Provider Signature

______________________________________________________ Date

Indemnification Agreement: By signing this waiver, I hereby agree to indemnify and hold harmless Sandhills Center from all losses, costs, damages, claims, liabilities and expenses (including attorneys’ fees and court costs) whatsoever, which may arise or be claimed against Sandhills Center, for any loss, injuries or damages, consequent upon or arising from any acts, omissions, neglect or fault in connection with Sandhills Center’s reliance upon this waiver.

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qmcappd 05/22/2018

ACKNOWLEDGEMENT AND AUTHORIZATION FOR SOCIAL SECURITY NUMBER CHECK

I, , hereby authorize Sandhills Center to verify my (Print Name)

Social Security Number through a third party consumer reporting agency for credentialing/re- credentialing purposes. This verification will be conducted by American DataBank, 110 Sixteenth St., 8th

Fl., Denver, CO 80202, 1-800-200-0853, www.americandatabank.com. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

All of the information requested below is mandatory and must be provided. Please type or print clearly.

Last Name: First Name: Middle:

Social Security Number*: Date of Birth*:

Present Address:

City/State/Zip:

Email Address:

Signature: Date:

*This information is limited to verification of the individual’s Social Security Number and will not beused for employment/hiring purposes. American DataBank’s privacy policy can be found athttp://www.americandatabank.com/consumer-information/privacy-policy/.

qmcappd 10/12/2017

Documents

Uniform Credentialing Application to Participate as a ...Copy of Curriculum Vitae or work history after graduation from Medical, Dental or other professional school. Cultural Competency