HERITAGE SUMMIT HEALTHCARE INC.
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? ......................................................................................................................
If yes, please list the electronic billing company or capability type (PDFs, scans, etc.)
What practice management system do you use?
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
3. Billing address _______________________________________________________________________
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
City State ZIP
County/Parish Phone ( ) Fax ( )
4. Is this location a walk-in clinic? ..................................................................................................................
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
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Administrative personnel
5. Administrator/CEO/CFO
Business office manager
Utilization review supervisor
Contract negotiator
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Facility
6. Is this facility corporate owned?..................................................................................................................
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)
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
8. Professional license number
NPI
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Medicare number Medicaid number
ASC license number FEIN
9. Name of professional liability carrier
Policy number
Amount of coverage
Staff
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
10. Number of active physicians on staff
Number of physicians on staff
Number of board-certified physicians
Number of nurses on staff
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
11. Number of nurses on staff
LPN
ARNP
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
RN
CRNA
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
12. Are the credentials of all your staff verified prior to their employment or affiliation with your facility?...........
Please attach a list of all staff physicians, their specialties and credentials.
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Accreditations
13. JCAHO accredited .................................................. Date of last accreditation
Medicare approved.................................................. Date of last inspection
CARF accredited (rehab hospital only) .................. 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 Inc. 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 Inc. signature Date
Facilities Only
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Type of facility: Ambulatory surgery center
Home health
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Other (please define)
Note: All physicians will need to apply to and be accepted by Heritage Summit HealthCare Inc. in order to provide network services.
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Hospitals Only
Type of hospital
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Bed counts
Intensive care unit
Critical care unit
Progressive care unit
Medical
Surgical
Other (please define)
Orthopedic
Obstetrics/Gynecology
Skilled nursing
Pediatric
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Please check which services are available in your hospital: Physical therapy
Occupational therapy
Speech programs
CT scan
MRI
Home health
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Does your hospital provide occupational medicine?
If yes, please list name(s) and address(es) below.
Name
Address
Does your hospital provide ambulatory surgery?
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).
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1
Heritage Summit HealthCare Inc.
Credentialing Review—Facility/Hospital page 1