ATTACHMENT_3_-_14-R-0011_-_3.pdf

CSOSA-14-R-0011

TREATMENT PROVIDER APPLICATION

I. Applicant

Provider Name_________________________________________________________________

Type of Provider________________________________________________________________

Street Address__________________________________________________________________

City________________________________State_________________Zip___________________

Phone Home_________________________Phone Business______________________________

Social Security Number____________________Tax ID_________________________________

Medicare Provider Number_________________Medicaid Provider Number________________

II. Liability Insurance

Carrier_____________________________Policy #______________Expiration Date__________

Coverage Amount

Per Account______________________________________Aggregate________________________

III. Other Locations

If the applicant provides services at more than one location, please list below:

1. ___________________________________________________________________________

2. ___________________________________________________________________________

3. ___________________________________________________________________________

Organization Name:

IV. Licensure

Type of License____________________Lic #___________State_______Date of Issuance_____

Type of License____________________Lic #___________State_______Date of Issuance_____

Please submit copies of all licenses, operating certificates and correspondence regarding accreditations and approvals of staff providing direct treatment.

V. Education

School Name/City_______________________________________Graduation Year__________

Degree:_________________

Residency Location:_____________________________________Yr. Completed____________

Board ___Certified ___Eligible Speciality:_________________________Date__________

Board ___Certified ___Eligible Speciality:_________________________Date__________

VI. Hospital Affiliations

Name____________________ Active/Courtesy (circle if applicable) % Admissions_______

VII. Other Information

(If you respond 'yes" to any of the following questions, please provide a detailed summary of circumstances and present status on a separate sheet of paper and attach it to this application)

Have there been any malpractice judgments against the applicant within the past five years?

______YES ______NO

Have any malpractice suits against the applicant been settled out of court within the past five years?

Are there any malpractice actions pending against the applicant at this time?

Denial, restrictions, limitation, suspension or revocation of licensure to practice in any jurisdiction?

Any physical or mental conditions which may impair ability to practice within the scope of work and/or applied privileges, including current treatment for substance abuse?

Organization Name:

Denial, suspension, or reduction of Medicaid or Medicare privileges?

Any pending felony or misdemeanor charges?

I, the undersigned, hereby attest and certify that the information given in or attached to this application is accurate and represents my current level of training, experience, and competence to provide services at the level requested. I understand that any misstatements in or omissions from this application shall constitute cause for summary dismissal. I further agree to promptly report any changes in this application information. I release from all liability those entities and persons who provide such information in good faith and without malice. I have read and understand the credentialing and other requirements listed in this application and agree to abide by same to continue participation in the CSOSA programs.

Signature Date