Heritage Summithealthcareinc

Aboutyou

HERITAGE SUMMITHEALTHCAREINC.

Application/CredentialReview—Provider

HeritageSummit HealthCare Inc.

Application/CredentialReview—Provider page1

First nameMILast nameSuffix(MD, DO, etc.)Date of birth

NPIFEINSSN

Primary specialtySecondary specialty (if applicable)

Your credentials

Forthis application to be valid, copies of the following documentation must be included at the time of submission. Please place a checkmark next to each item to indicate that you have included copies of each.

HeritageSummit HealthCare Inc.

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Current yearW-9

Workers’compensation certification

(Florida Only)

Medical license

DEA

Proof/copy of medical malpractice insurance,

letter of credit or escrow account

Provide list of all ownership, financialor

fiduciaryinterest facilities (Alabama only)

Curriculum vitae/resumé

American Board certificationor ECFMG

Academic professional degree(s)/

medical diploma

Internship(s)

Residency(ies)

Fellowship(s)

Other board certification(s)

HeritageSummit HealthCare Inc.

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Your practice

Practice name (if applicable)

Doyou have an investment interest in any other entity than those mentioned?...... pick oneYesNo

Ifyes, please specify.

Doyou provide services for work-related injuries?...... pick oneYesNo

Do you accept appointments for Independent Medical Evaluations (IMEs)?...... pick oneYesNo

Do you qualify as a minority provider?...... pick oneYesNo

Doyou wish to be recognized as a walk-in center?...... pick oneYesNo

Ifyes, do you:

Provide minor suturing?...... pick oneYesNo Have on-site X-ray capabilities?...... pick oneYesNo Collect drug specimens?...... pick oneYesNo Close for lunch?...... pick oneYesNo

HeritageSummit HealthCare Inc.

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Arethere other associates (MD, DO, DDS, DMD, OD, PA,ARNP, etc.) in your practice?...... pick oneYesNoIf yes, please list them below. Note:Foryourpracticetobeconsideredforournetwork,eachproviderwillneedtocompletethisapplicationinitsentirety.

Ifapplicable, please list your current primary admitting facility and other hospitals where you have privileges.

Your officelocation(s)Pleasecopy this page to list additional locations.

Group name (if applicable)

Primary location physical address

HeritageSummit HealthCare Inc.

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City

StateZIPcode

HeritageSummit HealthCare Inc.

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County/parish Phone () Fax ( )

E-mail addressWebsite (if applicable)

Isonline appointment scheduling available?...... pick oneYesNo

If yes, please specify if web address differs from the one listed above.

Officehours of operation

MondaytoThursday to Sunday to

TuesdaytoFriday to Please indicate lunch time:

HeritageSummit HealthCare Inc.

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WednesdaytoSaturday to From to

HeritageSummit HealthCare Inc.

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Group name (if applicable)

Secondary location physical address

HeritageSummit HealthCare Inc.

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City

StateZIPcode

HeritageSummit HealthCare Inc.

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County/parish Phone () Fax ( )

E-mail addressWebsite (if applicable)

Isonline appointment scheduling available?...... pick oneYesNo

If yes, please specify if web address differs from the one listed above.

Officehours of operation

MondaytoThursday to Sunday to

TuesdaytoFriday to Please indicate lunch time:

WednesdaytoSaturday to From to

HeritageSummit HealthCare Inc.

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Billing

1.Do you have electronic billing capabilities?...... pick oneYesNo

a. Do you use an outside vendor for billing?...... pick oneYesNo

If yes, please list your vendor’s name.

b.What practice management system do you use?

2.Should remittances to be sent to a billing address other than your physical location?...... pick oneYesNo

Ifyes, please list address:

3.Are your services billed using a tax identificationnumber of a group affiliation,IPA/PPO, etc.?...... pick oneYesNo

Ifyes, please provide applicable tax identificationinformation below.

Billingtax identificationnumber: Name assigned to this tax identificationnumber:

If you answered no, then it is assumed that you will bill using your FEIN.

Licenses/privileges

Important:If you answeryes to any question(s) 4–13, please attach a detailed explanation of each, including any applicable allegations, dates, outcomes and any other relevant information.

4.Has your license to practice medicine in any jurisdiction ever been limited, suspended or revoked?...... pick oneYesNo

Ifyes, is any action pending? (Please attach explanation.)...... pick oneYesNo

5.Has your narcotics registration ever been suspended or revoked, or otherwise acted against?...... pick oneYesNo

Ifyes, have you ever been notifiedto appear before any licensing agency for a hearing or

complaintof any nature? (Please attach explanation.)...... pick oneYesNo

6.Have your privileges or medical staff membership at any health care facility ever been denied,

suspended,revoked, limited or otherwise acted against?...... pick oneYesNo

Ifyes, is any action pending? (Please attach explanation.)...... pick oneYesNo

7.Have you ever been denied staff membership, or renewal thereof; or been subject to disciplinary action in any medical organization or by any licensing agency of any state, district, territorial

possessionor county?...... pick oneYesNo

Ifyes, is any action pending? (Please attach explanation.)...... pick oneYesNo

8.Have any medical malpractice claims or actions been filedagainst you in the past 15 years?...... pick oneYesNo

If yes, how many? (Please attach explanation.)......

9.Have any judgments or settlements been made against you in professional liability cases?...... pick oneYesNo

Ifyes, is any action pending? (Please attach explanation.)...... pick oneYesNo

10.Have you ever been convicted of, or pleaded no contest to, any criminal charges (other than motor

vehiclespeeding violations) brought against you?...... pick oneYesNo

Ifyes, is any action pending? (Please attach explanation.)...... pick oneYesNo

HeritageSummit HealthCare Inc.

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11. Have you ever had any civil action brought against you (other than malpractice claims)?...... pick oneYesNo

Ifyes, is any action pending? (Please attach explanation.)...... pick oneYesNo

12.Do you presently have a physical or mental health condition (including alcohol or drug dependence) that affects—or that may reasonably be expected to progress within the next two years to the point of affecting—your ability to maintain clinical privileges or perform other medical staff duties?

(Pleaseattach explanation.)...... pick oneYesNo

13.Have you ever been convicted of a criminal offense relating to your involvement in any programestablishedunder Medicare and/or Medicaid? (Please attach explanation.)...... pick oneYesNo

Applicantresponsibilities and release

Iconsent to and authorize the release of all information and documents relating to any disciplinary action, professional competence, suspension or curtailment of medical or surgical privileges (including malpractice claims and/or coverage) by any person or entity to Heritage Summit HealthCare Inc. (Heritage). I hereby release any such person or entity providing such information from any and all liability for doing so.

Iunderstand that I have the legal responsibility to provide Heritage with adequate information demonstrating my professional competence and otherqualifications.If it is determined that additional information is needed to complete this application, I understand that Heritage may request this information via phone orfax. I understand that failure to cooperate in providing this information within 45 days of the request may cease any contracting efforts, and this application will be considered void.

Iagree that I shall not begin performing services under contractual agreement until all credentialing information is submitted, approved, and Heritage Summit HealthCare Inc. and I have signed a contract.

Ifapplicable to my medical practice, I understand that each physician or group of physicians who supervise a certifiedphysician assistant must be qualifiedin the medical area in which the physician assistant is to perform.The physician(s) shall be individually or collectively responsible and liable for the performance and the acts and omissions of the physician assistant. I understand that under Heritage’s credentialing guidelines, I may not have more than two currently certifiedphysician assistants under my supervision.

Iagree to and certify that the above facts and information provided above are true and correct to the best of my knowledge.

Pleaseensure all documentation is attached. Aphotocopy of this document shall be as effective as the original.

Medical provider signatureDate

Nameof person completing application (if not provider)

Direct telephone number of person completing application

E-mail address of person completing application

Please return this form and all attachments to our corporate office(address below).

(Forofficeuse only)

______

Heritage Summit HealthCare Inc. representative signatureDate

HeritageSummit HealthCare Inc.

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