Health Care Practitioner

UniformApplication

To Participate as a

Health Care Practitioner

(LicensedIndependent Practitioner- LIP)

INSTRUCTIONS

AprospectiveLicensedIndependentPractitionermustapplyforandbe credentialedasa practitionerwithEastpointe toqualifyforreimbursementofservicesprovidedtoEastpointeconsumers. Additionally,Practitionersmusthavea signed contractwith Eastpointe orbe employedby anOrganization orGroup Practice thathasa signedcontractwith Eastpointe toqualifyfor reimbursementof services provided toEastpointe consumers.

Thecredentialingprocessincludes thefollowingsteps:

1. Providercompletesandsignsthe UniformApplicationtoParticipate asaHealth Care Practitionerand submits italongwith the requiredcredentials electronically to the link listed below.Applications submitted in manners other than this will not be processed:

Please submit it to our email address at . Please note that you may have to hold down the ctrl key on your keyboard as you click this link.

Forinquiriesregardingtheapplicationprocess,pleasecontact us at our email address at orby telephone at1 (888) 977-2160.

2. AUniformApplicationtoParticipateasaHealthCarePractitionerisconsideredtobeinvalidandmustbe returnedtothe provider forcorrection and/orforadditional information if:

The versiondateonanyofthedocumentsthatcomprisetheproviderenrollmentpacketispriorto April 2, 2012

Allspacesintheapplicationhavebeencompleted. (Pleaseindicate“N/A”or“None”,ifthequestion is notapplicable)

TheSignatures,where required,are notoriginal

TheSignaturesare not bythe individual applicant

Thetexthasbeenaltered,highlighted,struckthrough,orobstructedthroughtheuseofcorrection fluids

Theresponsesare illegible

TheNational ProviderIdentifierisnot a valid number

AnyofthedocumentsorpagesthatcomprisetheUniformApplicationtoparticipateasaHealthCare Practitioner aremissing

AnyoftherequestedinformationinanyofthedocumentsthatcomprisetheUniformApplicationto participateasaHealth CarePractitionerismissing,withtheexceptionofthe fax numberand e-mail address

BeforesubmittingtheApplication, makesureyou have completedthe following:

Include ananswerinallspaces. Indicate“N/A”or“None”, ifthequestionisnot applicable

Thepractitionerforwhom the Application is being submittedhas signedand datedthelastpage of the Application

BeforesubmittingtheApplication, makesureyou have enclosed thefollowing,if applicable:

Copyoftheprovider’soriginal state(s) license(s) and current registration. If provisionally licensed,submit a current copyofyour supervision contractandcompletethe clinical supervisorinformationon page7 of thisapplication.

CopyofcurrentFederalDEA certificate (forMDs,PhysicianAssistantsand PsychiatricNurse Practitioners). TheCertificatemusthave avalid date and refer to currentaddress.

CopyofSouthCarolinaControlled DrugSubstance Certificateand DEA information, ifapplicable

Copyofthefacesheetof yourcurrent professional liability insurance policy,indicatingbyname,provider(s) covered,coverage amounts, effective date,expiration date,and policynumber.Attachpreviouscarrierface sheet.

Proofof professional liability insurancefornon-physician providerswho careforpatients in yourpractice.Coverage amounts$1,000,000/ $3,000,000

CopyofNational Provider Identifier(NPI) Certification LetterforAgencyand Clinician(s).

Copyofcertificatefromthe Specialty Board, ifapplicable.

CopyofEducational Commission of Foreign Medical Graduate Certificate-ECFMG,ifapplicableCopy of Curriculum Vitae (CV) or work history after graduation from Medical, Dental, or obtaining a Bachelors/Master’s degree for non-physician applicants. The CV must account for any gaps of one hundred eighty (180) days or more.

CopyofW-9 Form.

Examples ofdocumentationtoattachtothisapplication:

Eastpointe 4.21.2017

OriginalN.C.LicenseDEARegistrationMedicalBoard Registration

BoardCertificationCertificateof

Insurance

Eastpointe, 4.2.2012

1.NameofApplicant:Last Name First Name Middle Maiden

2.DateofBirth: PlaceofBirth:

SocialSecurityNumber Sex:Male Female

3.TypeofPractice:

PrimaryCareSpecialist

PleaseIdentifyAreasofClinicalExpertiseandtreatmentbycompletingandsigningthe Practice

PreferenceDataon theattachedCultural,Racial,Ethnic,Gender,andLinguisticDataForm.

Whatpopulation(s)doyoutreat(e.g.,geriatric,allages)?

Language(s)Spoken,includingsignlanguage:

Are interpreters available?

4.NameofPractice:

5.PrimaryOffice Address(Ifyoumaintainmorethanoneoffice,listeachoffice,address,andhoursof operation.)

PracticeName

Street City County State Zip

Office Phone:Fax Email

AcceptingNew Patients? Yes NoRestrictions:

Handicappedaccessible? Yes No

Ifno,explainhowyou wouldaccommodateahandicappedconsumer

OfficeHours

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday

SecondaryOffice Address(Ifyoumaintainmorethanoneoffice,listeachoffice,address,andhoursof operation.)

PracticeName

Street City County State Zip

Office Phone:Fax Email

AcceptingNew Patients? Yes NoRestrictions:

Handicappedaccessible?

Ifno,explainhowyou wouldaccommodateahandicappedconsumer

OfficeHours

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday

AdditionalOffice Address or Billing Address, if different (check one) Billing Office

PracticeName

Street City County State Zip

Office Phone:Fax Email

AcceptingNew Patients? Yes NoRestrictions:

Handicappedaccessible? Yes No

Ifno,explainhowyou wouldaccommodateahandicappedconsumer

OfficeHours

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday

6.Nameotherprovider(s)in yourpractice(ifnotenoughspace,pleaseattachadditionalsheet):

7.Donursepractitioners,physicianassistants,midwives,socialworkers,orothernon-physician providersprovidecaretopatientsin yourpractice? Yes No

[Ifyes,pleaseattachproofofprofessionalliabilityinsurance,proofofemploymentforthoseindividuals,anda copyoftheirNationalProviderIdentifier(NPI)CertificationLetter.]

8. Nameandaddressofprovider(s)whosharecallwithyou(ifnecessary,pleaseattachadditionalsheet)

Name:Address:

9.Specifythearrangementsfor24hour/7daycoverage(apartfromandinadditiontoCommunity Emergency ResponseServices(i.e.911,EmergencyDepartment,etc.)

10.AdministrativeContact:

Name Title Telephone

11.IRSrequiresreimbursementbemadepayabletonameofpracticeaffiliatedwithFederalTaxID Number. FederalTaxID Number

Name(if differentfrompracticename)

BillingAddress (ifdifferentfrompracticeaddress)

12.UPINNumber Medicare/MedicaidNumber

13.DEANumber(Attachcopytoapplication)Exp. Date

14.NationalProviderIdentifier(NPI)Number

(AttachcopyofNPICertificationLettertoapplication)

COMPLETE ONLYIF LICENSED IN SOUTH CAROLINA

SCControlledDrugSubstanceCertificate ExpirationDate

(Attach copy to application)

15.Provide the following informationforeachstate inwhich you arecurrentlyorwerepreviouslylicensed to practice(If necessary,please attach additional sheet):

STATE / DATE OF
LICENSE / LICENSE
NUMBER / LICENSE TYPE / STATUS:
Active,Inactive, Suspended / EXPIRATION
DATE

PLEASEATTACHACOPYOFEACHSTATELICENSECERTIFICATE

Ifprovisionallylicensed,providea copyofyourcurrentsupervisioncontractandthenameandcontact informationfor yourclinicalsupervisor:

ClinicalSupervisor Phone E-mail

Street City State Zip

16.CertificationofSpecialtyBoardsas applicable

a.Ifyouarecertifiedbyaspecialtyboard,indicatenameof boardanddateofcertificate.

Primary Specialty BoardDateCertified Exp.Date

Secondary Specialty BoardDateCertified Exp.Date

b.Ifyouhaveappliedtoaspecialtyboardforexamination,givethenameof boardandthedateofthe scheduledexamination. Date

c. If youhave not appliedto a specialty board, please explain”

17.Listthedatesof allcurrentprofessionalmembershipsinsocieties,includingstateandcountysocieties:

Professional MembershipFROM / TO:

18.Listallhospitalswhereyoucurrentlyhaveprivilegesandindicatethetypeandstatusofthose privileges:(Type:active,admitting,associate,consulting,courtesy. Status:pending,provisional,suspended, temporary,visiting)

Hospital / PrivilegeandStatusof Privilege / Estimated%ofAdmission

19.Ifyou do nothave admitting privileges,whoadmits foryou?

NameAddress Phone

1.Medical,DentalorotherProfessionalSchoolAttended:(“SeeResume”isnotacceptable.)

Institution

Address:

City State Zip

Degree From To

Name as it appears on degree:

PleaseattachEducationalCommissionofForeignMedicalGraduateCertificate- (ECFMG),ifapplicable.

2.Internship

Institution

Address:

City State Zip

Specialty From To

3.Residency

Institution

Address:

City State Zip

Specialty From To

4.OtherResidency/Fellowship-(specify

Institution

Address:

City State Zip

Specialty From To

5.Listwork historysince beginning ofmedical,dentalorotherprofessionalschool (minimum of last5 years of relevant work history or complete work history if practicing less than 5 years)and explain anyemploymentgapslonger than 6months;please be specific. Application will not be processed without this information. See “Resume” is not acceptable.(If notenough space,please attach additional sheet)

Current practiceFrom To

Previous practiceFrom To

6.Listother training and/oreducation (including CME)within the last threeyears.

7.Have you involuntarilyor voluntarilywithdrawn,orbeen suspended fromanyinternship,residency or fellowship training program?Please explain:

8.Please explain anyincident(s) inwhich you have involuntarilyorvoluntarilywithdrawn your application forappointment,clinicalprivileges orreappointmentbeforeadecisionwas madebya hospitalorhealthcare facility’s governingboard:

Please check Y for yes or N forno for the following questions.Please completetheattached SupplementalForm foranyquestions towhich you answer“yes.”Also, pleasesign and datethisapplication.If this application does nothave the provider’s signature,itcannotbe accepted.

1.Hasyourlicenseto practiceinanyjurisdictioneverbeenlimited,restricted,reduced,suspended,
voluntarilysurrendered,revoked,deniedornotrenewed;have youeverbeenreprimandedbya statelicensingagency;or areanyoftheseactionspendingwithrespecttoyourlicense;areyou underinvestigationbyanylicensingorregulatoryagency?
(Ifyes,pleasecompleteSupplementalQuestion No.1) / Yes / No
2.Hasyourprofessionalemploymentormembershipinaprofessionalorganizationeverbeensubjectto
disciplinaryproceedings,denied,limited,restricted,reduced,suspended,revoked,notrenewed,or voluntarilyrelinquishedduringorunderthreatof terminationforanyreason?
(Ifyes,pleasecompleteSupplementalQuestionNo.2.) / Yes / No
3.HasyourDrugEnforcementAgencyregistrationorothercontrolledsubstanceauthorizationeverbeen limited,restricted,reduced,suspended,revoked,denied,notrenewed,or have youvoluntarily surrenderedor limitedyourregistrationduringorunderthethreatofan investigationoranysuch actionspending?
(Ifyes,pleasecompleteSupplementalQuestionNo.3.) / Yes / No
4.HaveyoueverbeensanctionedorsuspendedbyMedicareorMedicaid?
(Ifyes,pleasecompleteSupplementalQuestionNo.4.) / Yes / No
5.Toyourknowledge,haveyoueverbeenreportedtotheNationalPractitionerDataBankorthe
North/SouthCarolinaBoardofMedicalExaminers?
(Ifyes,pleasecompleteSupplementalQuestionNo.5.) / Yes / No
6.Haveyoueverbeenconvictedof afelonyormisdemeanor,orareyouunderinvestigation with respecttosuchconduct?
(Ifyes,pleasecompleteSupplementalQuestionNo.6.) / Yes / No
7.Hasa professionalliabilityclaimbeenassessedagainstyouinthepastfiveyears,orarethereany
professionalliabilitycasespendingagainst you?
(Ifyes,pleasecompleteSupplementalQuestionNo.7.) / Yes / No
8.Hasanyliabilityinsurancecarriercanceled,refusedcoverage,orratedupbecauseof unusualrisk orhaveanyproceduresbeenexcludedfromyourcoverage?
(Ifyes,pleasecompleteSupplementalQuestionNo.8.) / Yes / No
9.Have youeverpracticedwithoutliabilitycoverage?
(Ifyes,pleasecompleteSupplementalQuestion#9.) / Yes / No
10.Doyoucurrentlyhaveanymedical,chemicaldependencyorpsychiatricconditionsthatmight adverselyaffectyourabilitytopracticemedicineorsurgeryorto performtheessentialfunctionsof
yourposition?
(Ifyes,pleasecompleteSupplementalQuestionNo.10.) / Yes / No
11.HaveyourHospitaland/orClinicprivilegeseverbeen limited,restricted,reduced,suspended,
revoked,denied,notrenewed,orhaveyouvoluntarilysurrenderedor limitedyourprivilegesduring orunderthethreatofan investigationorareanysuchactionspending?
(Ifyes,pleasecompleteSupplementalQuestionNo.11). / Yes / No

Signature:Date:

Allspaces inthe applicationmustbecompleted.

(Pleaseindicate“N/A”or“None”, if thequestion isnotapplicable)

Provider Name:Provider ID#

1.LicenseLimited,Reprimanded,etc.

ListState(s)where action tookplace:

Date(s) license revoked,suspended,etc.From To

Please explain:

2. Employment/Membership SuspendedLimited, etc.

ListState(s)where action tookplace:

ListProfessional Organization

Please explain:

3. Drug Enforcement Agency (DEA) Explanation

ListState(s)where action tookplace:

Please explain:

4. Medicare/Medicaid Sanction Disciplinary Action(s)

Disciplined Action(s):

ListState(s):

Date(s)of ActionFrom To

Please explain:

5.NationalPractitionerDataBankReport(s)

Please explain the NPDBreport(ifyou have a copyplease attach):

6.FelonyorMisdemeanor

Did you serve a sentence? Yes NoIf YES,howmanyyears?

Please explain charge and verdict

List States

7.NamedinProfessionalLiabilityJudgment,Settlement,etc.

Please explain,include dates & amounts

Provider Name:Provider ID#

8.Canceled,RefusedCoverage,etc.

PleaselistInsurance Carrier(s)

Please explain:

9.PracticedWithoutLiabilityCoverage

Please explain:

10. Medical,ChemicalDependency,orPsychiatricConditions

Please explain in detail:

11.HospitalorClinicPrivilegesRevoked,Restricted,etc.

ListHospital(s)

Date privileges revoked,suspended,etc.From To

Please explain:

1. List all partners, managing employees and Electronic Funds Transfer (EFT) authorized individualsassociatedwith yourpractice, andprovide theinformation requestedon each

NameandAddress / Title / SSN / License# / %Owner
DateofBirth
Checkbusinessrelationshipthatapplies:
OwnerShareholderPartnerManager
EFT AuthorizedStaff
Checkrelationshiptoenrollingprovider(if applicable):SpouseParentChildSibling
NameandAddress / Title / SSN / License# / %Owner
DateofBirth
Checkbusinessrelationshipthatapplies:
OwnerShareholderPartnerManager
EFT AuthorizedStaff
Checkrelationshiptoenrollingprovider(if applicable):SpouseParentChildSibling
NameandAddress / Title / SSN / License# / %Owner
DateofBirth
Checkbusinessrelationshipthatapplies:
OwnerShareholderPartnerManager
EFT AuthorizedStaff
Checkrelationshiptoenrollingprovider(if applicable):SpouseParentChildSibling
NameandAddress / Title / SSN / License# / %Owner
DateofBirth
Checkbusinessrelationshipthatapplies:
OwnerShareholderPartnerManager
EFT AuthorizedStaff
Checkrelationshiptoenrollingprovider(if applicable):SpouseParentChildSibling

2. Doyouhaveownershiporcontrolinterestof5%ormoreinotherorganizations thatbillsMedicaidfor services. Yes No

Ifyes,pleasefill inthefollowingforeachorganization.

Organization Legal Business Name

Employer Id. No

Medicaid No

ENROLLMENT CATCHMENT AREA

Please check the counties(s) for which you are applying:

Bladen Columbus Duplin Edgecombe Greene Lenoir Nash

Robeson Sampson Scotland Wayne Wilson

Other (Please Specify)

Attestation Statement - LIP

(IMPORTANT:SubmitOriginal Only)

ThisApplication istobe signed byeach individualprovider submitting an application.

No Stamps or CopiesPlease

Allinformationsubmitted bymeinthisapplication,aswellasanyattachmentsorsupplementalinformation, istrue, current,and completeto my best knowledgeandbeliefasofthe date ofsignaturebelow.Ifullyunderstandthatany significantmisstatementinthisapplicationmayconstitutecausefordenialofmyapplicationorterminationofa resultingparticipationagreement.

ByapplicationformembershipinEastpointeNetwork,Isignifymywillingnesstoappearforinterviewinregardtomy application.IauthorizeEastpointetoconsultwithadministrators andmembersofthemedicalstaffsofhospitalsor institutionswithwhichIhave beenassociatedandwithothers,includingpast andpresentmalpracticecarriers,who mayhaveinformationbearingonthequestionsinthisapplication.Uponrequest,IwillobtainandprovidetoEastpointematerialspertainingtomyqualifications andcompetence,including, materialsrelatingtocomplaints filed,any disciplinaryaction,suspension,or actiontocurtailmymedical-surgicalprivileges.Ifurtherconsenttotheinspection byrepresentativesof Eastpointeofalldocumentsthatmaybematerialtoanevaluationofmyprofessionalqualifications andcompetence.

IunderstandandagreethatI,asanapplicant,havetheburdenofproducingadequateinformationforproper evaluationofmyprofessionalcompetence, character,ethics,andotherqualificationsandforresolvinganydoubt aboutsuchqualifications.Ireleasefromliabilityallrepresentativesof Eastpointefor theiractsperformedingoodfaithand withoutmaliceinconnectionwithevaluatingmyapplicationandmycredentialsandqualifications,andIrelease fromanyliability,allindividualsandorganizations thatprovideinformationto Eastpointeingoodfaithandwithoutmalice concerning thisapplicationandIhereby consenttothereleaseandverification ofinformation relatingtoany disciplinaryaction,suspension,orcurtailmentof medical-surgicalprivilegesto Eastpointe.

Iunderstandthatifmyapplicationisrejectedforreasonsrelatingtomyprofessionalconductorcompetence, Eastpointemayreporttherejectiontotheappropriatestate licensingboardand/orNationalPractitionerDataBank.Intheevent IamacceptedforparticipationinEastpointeNetwork,IherebyconsenttoEastpointeforinspectionofmypatientrecords relatingto Eastpointeenrolleesasnecessaryforitspeerandutilizationreviewpurposesaspermittedbystateorfederal lawandregulation.Ifurtheragreetonotify Eastpointeinatimely manner(nottoexceed30days)ofanychangestothe informationrequestedontheinitialapplication.

PRINTNAME OF PROVIDER

SIGNATURE OF PROVIDER

DATE

PleaseSignandDatethisAttestationStatement

Eastpointe 4.21.2017