Practice Name:______(please print)
Practice Address:______(please print)
Street City State Zip
Main Phone______Main Fax______Main Email______
Main Contact:____________Preferred Method of Contact: ___Ph ___Fx ___Email
Practice Administrator:______Ph/Email ______
Billing Contact: ______Ph/Email______
In 2015, I Will Participate in the following manner: PLEASE CHECK ONE BELOW
Primary Care Practice/Group
____As an Individual Practitioner, providing services to 10 approved Project Access patients through my office.
Specialty Care Practice/Group
____As an Individual Practitioner, providing services to 6 approved Project Access patients through my office.
____As a Group of 2-3 Providers, providing services to 12 approved Project Access patients through our office.
____Group of 4-5+ Providers, providing services to 22 approved Project Access patients through our office.
____Group of 6+ Providers…for each additional Provider please add 4 patients to the total…_____ patients total
Other Provider
____Case by Case [General] – I/We will not put a minimum or maximum on my participation, but will review patient cases as they are presented to decide if they will be accepted for service.
____Case by Case [Specific] – I/We will agree to see this specific patient ______
____Other – I/We wish to participate in the following manner: (please indicate if your office has its own internal charity program or discount options based on a patient’s income) ______
______
Non-Participation
____ I/We have reviewed the Project Access Program information sent (along with any Patient consult/service request attached) and are declining participation at this time.
Person Completing Form:______Title:______
Signature:______Date:______
Please see Page 2
SubSPECIALTIES / Participating
as a Group Equally / Individual Number from Total / CREDENTIALS / LICENSE NO. W/
EXPIRATION DATE
Ex. John Smith / Internal Medicine / P / n/a / M.D. / 23001 12/01/2014
Please only list the Providers who will be seeing Project Access Patients – Only Providers who participate can refer
If those listed below will share the commitment level equally, simply check the Participating as a Group Equally box. For example, your group may commit to seeing 20 patients for the year, list 4 Providers, check the box, and we will divide the 20 giving each Provider 5 patients. If you group will see 20 patients, but 2 of your Providers wish to see 2 each, and the other 2 want to see the rest, put 2 in the Individual Number from Total column for the Providers who wish to see 2, and 8 in the column for the Providers who wish to see the remaining 16 patients
·Diagnoses: Are there certain diagnoses or conditions you wish to see? Any which you prefer not to see?
______
______
·Scheduling: How would you like us to schedule with your office?
______
Do you have a specific internal form you would like completed? ______[if so, please provide]
Do you want to review records before accepting a patient? ______
·Billing: Please send your Insurance/Claim Forms (HCFA/CMS-1500 Forms) for the services you will be writing off for each patient. How & how often will you be able to communicate this to us?
______
·Other:______
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