PWS ATTACHMENT C- CREDENTIALING APPLICATION REQUEST EXAMPLE.docx

Credentialing Application Request For:

Date:

Thank you for your interest in providing services to Veterans through the Veterans Health Administration Office of Community Care (VHA OCC). Enclosed is a Credentialing Application; its completion and submittal are necessary in order to begin your credentialing/recredentialing process.

Please complete your application package as described below:

1. Complete the Credentialing Application Form

1. Sign and date the enclosed Disclosure Questionnaire

Please note that failure to provide the required information in a timely manner can jeopardize the status of your Veteran Care Agreement with the VHA Office of Community Care.

If you have any questions about responding to this request, please contact the credentialing office at the Office of Community Care at OCCCredentialing@va.gov

The VHA OCC appreciates your continued support in providing care to our Nation’s Heroes!

Credentialing Application Form :

Legal business name:

Doing business as (if applicable):

Administrator (full name):

Credentialing Contact Phone:

Secure Fax:

Medicaid Number:

Medicare Number:

Practice location name:

Address line 1:

State: Zip: County: City:

County:

(list as many licenses as applicable)

License:

State:

Accreditation, Certificate #: Accreditation, Certificate Expiration:

Unaccredited Organizations:

Has a site survey been completed by CMS or a state agency? Yes No

If Yes: Date of Most Recent Full Survey___________________

Is accreditation being pursued? Yes No

If Yes: Expected Date of Accreditation (MM/DD/YYYY) ___________________

Professional Liability Insurance

Current carrier name:

Effective date:

Expiration date:

Per incident: $

Aggregate: $

Entity/Group Practice Disclosure Questionnaire

Has the following ever been, or are they in the process of being - either on a voluntary or involuntary basis - Denied, Revoked, Suspended, Reduced, Limited, Placed on Probation, Not Renewed, Withdrawn, or Relinquished While Under Investigation:

1.) State Controlled Substance Registration?

Yes No N/A

If yes, please explain:

2.) Membership in any hospital, agency, insurance program and medical staff or as a participant in a research program been the subject of focused individual monitoring?

Yes No N/A

If yes, please explain:

3.) Other Health Care Organizations (PPO, MCO, etc)?

Yes No N/A

If yes, please explain:

4.) Professional Society Membership?

Yes No N/A

If yes, please explain:

5.) Has your group practice/entity or any individual employed by your organization ever been convicted of a felony?

Yes No

If yes, please explain:

6.) Has your group practice/entity or any individual employed by your organization ever been involved or notified that the quality of the care you provided is being reviewed as part of an administrative (e.g., Administrative Tor Claim), or judicial proceeding in which professional malpractice has been alleged?

Yes No

If yes, please explain:

The following include only “yes” “no” question:

7.) Has your entity or group practice ever been convicted of, and/or investigated for: making and/or using false, fictitious, or fraudulent statements, representations, writing or documents regarding a material fact in connection with the delivery of, or payment for, healthcare benefits, items or services that would be in violation of the Criminal False Claims Act?

Yes No

If yes, please explain:

I, the undersigned authorized agent, hereby attest that the information submitted in, or in support of this application is true, accurate and complete to the best of my knowledge and belief and is furnished in good faith. I understand that significant omissions or misrepresentations may result in denial of application or termination of privileges, employment or participating practitioner agreement.

Preparer Name: Title:

Signature: Date: