Physician/Clinical Expert Reviewer Application Packet

RETURN COMPLETED FORMS TO:

Cat Tibbett

Credentialing Coordinator

Permedion, Inc., an HMS company

350 Worthington Road, Suite H

Westerville, OH 43082

ph: (800) 473.0802 • (614) 895.9900

fax: (614) 895.6784

e-mail:

PERMEDION PHYSICIAN/CLINICAL EXPERT REVIEWER APPLICATION

Please Print

Name: / MD DO DDS DC
Other:
LAST / FIRST / MI
Specialty: / Date of Birth:
Are you currently, and have you been for at least 5 years, in active practice? Yes__ No__
If no, please explain: ______
# Hours each week devoted to active practice:
Approximate # of patients seen weekly:
Medical License #: / State: / Year Licensed:
Medical License #: / State: / Year Licensed:

Please attach a separate sheet for additional licenses.

Has your medical license ever been restricted, suspended, or revoked: Yes___ No___

If so, please attach a description of the event(s) associated.

Board Certified: / Yes___ No____ / (Please attach copy of certificate)
Specialty: / Year Certified:
Expiration Date
Subspecialty: / Year Certified:
Expiration Date:
Do you have a practice special interest/focus?
Are you currently or have you in the past been listed on the Office of Inspector General's (OIG) List of Excluded Individuals/Entities (LEIE)? Yes____ No ____
If yes, please attach a description of the event(s) associated. Please note that Permedion-HMS checks the OIG database regularly.
Business Address:
Contact or N/A:
Phone: / Cell: / Fax: / E-mail:
Home Address:
Phone: / Cell: / Fax: / E-mail:

What is your preffered method of contact? ______

Which address do you prefer as a mailing address: Home ______Office ______

Please note that the address on your W9 will serve as your payment address

Special instructions regarding contact if you cannot be reached at the above location:
Are you willing to perform reviews of medical records posted on the web? (High speed internet access required) Yes ___ No____

Do you have active staff privileges? Yes___ No___

If yes, please list the hospital(s) and city where you have privileges:
Have your hospital privileges ever been restricted, suspended, or revoked? Yes___ No___

If yes, please attach a description of the event(s) associated.

Have you performed, or are you performing Health Care Utilization Management or organizational independent medical peer reviews?
If yes, please list these organizations:
Do you have health care utilization or quality review experience? Yes___ No____
If yes, give details of participation (i.e., name of organization, committee, dates of service, responsibilities):

For informational purposes (not contractual), how many hours are you available weekly? _____

Are you willing to accept case in which you may be required to provide professional testimony for legal proceedings? Yes____ No_____
Have you provided professional testimony for legal proceedings in at least 2 cases? Yes__ No__

Please include copies of the following:

Copy of Curriculum Vitae
Signed Contract and Business Associate’s Agreement
Signed Confidentiality Statement
Copy of current license(s)
Completed W-9
Permedion – HMS Disclosure Requirements
Application:
Proof of Hospital Privileges/Affiliations (if applicable)

Signature: ______Date: ______