1. business and industrial

PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
Tips to avoid processing delays:
APPLICATION SIGNATURE: THIS APPLICATION MUST BE SIGNED BY THE AUTHORIZED OFFICIAL.
THE DELEGATED OFFICIALS SIGNATURE IS OPTIONAL. THE FOLLOWING PAGES MUST BE SIGNED 5, 11, 13 & 15).
SECTION 1. PROVIDER IDENTIFICATION INFORMATION
Identify the type of organizational structure of this Provider (Check One)
Corporation
Partnership
Sole Proprietor
Other: (Specify)_____________________________
Indicate if the Services include REFRACTION:
YES
NO
SECTION 1A - SOLE PROPRIETORS INFORMATION: This area captures the Owner’s Information (if applicable)
1. Full Legal Name of Person (including paternal and maternal last names) associated with this Social
Security Number:
2. Social Security Number:
SECTION 1B - PRIMARY OFFICE INFORMATION
3. Legal Business Name (Not Doing Business As):
4. Other Name (If Applicable): (Corporation or DBA)
6. NPI #:
5. Type of Other Name (If Applicable):
Doing Business As Name
7. Medicare #:
Other: (Specify) _______________________
8. Medicaid #:
N/A
N/A
9. Physical Address (Street Name, Number and Suite):
11. State:
12. Zip Code:
13. Telephone:
10. City:
14. Fax:
15. Email:
16. State of Local Facility Operating License Number and Expiration Date for Primary Office
1B1 - CONTACT INFORMATION FOR PRIMARY OFFICE
17. Name and Title of Contact Person
18. Contact Person Telephone Number:
19. Contact Person Fax Number
1B2 - CORRESPONDENCE ADDRESS (Check One):
Same as Physical
If no, please complete below
20. Mailing Address Line 1 (Street Name, Number and Suite):
21. City/Town:
24. Telephone Number:
26. Email Address (If Applicable):
Page 1 of 17
25. Fax Number:
22. State:
23. Zip Code:
Provider Application Form- Vision Services
02-2015
PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
1B3 - BUSINESS OFFICE HOURS FOR PRIMARY OFFICE
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
1B4 – MEDICAL STORAGE FACILITY
27. Medical Record Storage Facility (Check One):
Same as Physical
If no, please complete below, and please indicate for
Current Patients
28. Storage Facility Address Line 1 (Street Name and number):
29. Storage Facility Address Line 2 (Suite or Room):
33. Telephone Number:
Former Patients
30. City/Town:
34. Fax Number:
Both Current and Former Patients
31. State:
32. Zip Code:
35. Email Address (If Applicable):
SECTION 1C - ADDITIONAL OFFICE INFORMATION (For additional offices, make copies of this section, complete and submit)
No
Yes and complete information below included in this section.
36. Legal Business Name (Not Doing Business As):
37. Other Name (If Applicable): (Corporation or DBA)
38. Type of Other Name (If Applicable):
Doing Business As
Other: (Specify) _____________________
39. NPI #:
40. Medicare #:
41. Medicaid #:
N/A
N/A
42. Physical Address (Street Name, Number and Suite):
44. State:
45. Zip Code:
46. Telephone:
43. City:
47. Fax:
48. Email:
49. State of Local Facility Operating License Number and Expiration Date for Additional Office
1C1 - CONTACT INFORMATION FOR ADDITIONAL OFFICE
50. Name and Title of Contact Person
51. Contact Person Telephone Number:
52. Contact Person Fax Number
1C2 - CORRESPONDENCE ADDRESS (Check One):
Same as Physical
If no, please complete below
53. Mailing Address Line 1 (Street Name, Number and Suite):
54. City/Town:
57. Telephone Number:
59. Email Address (If Applicable):
Monday
Page 2 of 17
58. Fax Number:
55. State:
1C3 - BUSINESS OFFICE HOURS FOR ADDITIONAL OFFICE
Tuesday
Wednesday
Thursday
Friday
56. Zip Code:
Saturday
Provider Application Form- Vision Services
02-2015
PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
1C4 – MEDICAL STORAGE FACILITY
60. Medical Record Storage Facility (Check One):
Same as Physical
If no, please complete below, and please indicate for
Current Patients
61. Storage Facility Address Line 1 (Street Name and number):
62. Storage Facility Address Line 2 (Suite or Room):
66. Telephone Number:
67. Fax Number:
Former Patients
63. City/Town:
64. State:
Both Current and Former Patients
65. Zip Code:
68. Email Address (If Applicable):
SECTION ID - EMPLOYEES INFORMATION (For additional employees, make copies of section 1D, complete and submit information)
Employee Roster must include first name and two last names for all Managing Employees, which means a general manager,
business manager, administrator, director, or other individual that exercises operational or managerial control over, or who directly
or indirectly conducts, the day-to-day operation of the institution, organization or agency ether under contract or through some
other arrangement, whether or not the individual is a W-2 employee (42 CFR §420.200). Roster needs to include list of healthcare
professionals rendering services.
Name
Professional License
Professional License #
(Father's last name, Mother's last name, First
Title
Exp. Date
(if applicable)
Name, MI)
(if applicable)
Page 3 of 17
Provider Application Form- Vision Services
02-2015
PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
SECTION 1E - OPTOMETRIST OR OPHTHALMOLOGIST INFORMATION FOR PRIMARY OFFICE
69. Last name
70. First
71. MI
72. Date of Birth (MM/DD/YY)
73. DEA Number:
Expiration Date:
74. ASSMCA Number:
76. License Number
Expiration Date:
77. State College Membership Number
(Colegiación) and Exp. Date
78. Medicare#:
79. Social Security Number:
80. Email Address:
81. NPI Number:
82. Are you practicing as a physician more than
(twenty) 20 hours per week?
83. Which languages do you speak fluently?
84. Type of Specialty
English
Yes
Spanish
Expiration Date:
75. Male
Female
Other:________
No
1E1 - OPTOMETRIST OR OPHTHALMOLOGIST OFFICE HOURS FOR PRIMARY OFFICE
Tuesday
Wednesday
Thursday
Friday
Monday
Saturday
SECTION 1F - INFORMATION OF ADDITIONAL OPTOMETRIST OR OPHTHALMOLOGIST AT THIS LOCATION
85. Last name
86. First
87. MI
88. Date of Birth (MM/DD/YY)
89. DEA Number:
Expiration Date:
92. License Number
Expiration Date:
95. Social Security Number:
98. Are you practicing as a physician more than
(twenty) 20 hours per week?
90. ASSMCA Number:
91. Male
Female
93. State College Membership Number
(Colegiación) and Exp. Date
94. Medicare#:
96. Email Address:
97. NPI Number:
99. Which languages do you speak fluently?
100. Type of Specialty
English
Yes
Expiration Date:
Spanish
Other:_________
No
Monday
1F1 - OPTOMETRIST OR OPHTHALMOLOGIST OFFICE HOURS FOR PRIMARY OFFICE
Tuesday
Wednesday
Thursday
Friday
Saturday
For Additional Providers in this location, Please make copies of this page and attach to application. Please list providers for this
site, including all information below and who are providing patient care under your NPI, Professional Liability and Tax ID Number:
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Provider Application Form- Vision Services
02-2015
PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
SECTION 1G – HANDICAP ACCESS REQUIREMENTS
Primary Office
Additional Office, If Applicable
Both Primary and Additional Office
SECTION 1H – IDENTIFY OFFICIAL SIGNATURE
Authorized Official
Delegated Official
I attest that this facility complies with state and local requirements for handicap access as well as the standards required by the
Federal Americans with Disabilities Act of 1990, which became effective in 1992.
(Name/Title)
(Signature)
(Date) (mm/dd/yyyy)
SECTION 2.- MALPRACTICE CLAIMS HISTORY AND PROFESSIONAL LIABILITY INSURANCE
2A. MALPRACTICE CLAIMS HISTORY:
Has the Institution, persons affiliated with your entity or employees, within the last 10 years resulted in
either a malpractice claim settlement or disposition?
Have the Institution, persons affiliated with your entity or employees, within the last 10 years had any
malpractice suit, including arbitration?
Yes
No
Yes
No
If you answered yes to the previous two (2) prior questions, please explain:
SECTION 2B - PROFESSIONAL LIABILITY INSURANCE
Have you, the entity, persons affiliated with your entity or employees, ever been denied professional liability
insurance or has your coverage ever been cancelled or not renewed.
If “Yes,“ please explain
___________________________________________________________________________
Yes
___________________________________________________________________________
SECTION 2C -COMPLETE PROFESSIONAL LIABILITY INSURANCE INFORMATION
Present Carrier’s Name ______________________________________________________________________
Policy Number __________________________ Policy Limits_____________/______________
Effective Dates (From)_______________(To)________________
Page 5 of 17
Provider Application Form- Vision Services
02-2015
No
PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
SECTION 3. - INFORMATION ON PERSONS CONVICTED OF CRIMES- This section captures FINAL ADVERSE ACTIONSINFORMATION OF PERSONS CONVICTED OF CRIMES- OF APPLICANT/ PROVIDER. Answer the following questions by checking
"Yes" or "No". If any of the questions are answered "Yes", COMPLETE in spaces provided. This section captures information on
final adverse actions, such as convictions, exclusions, revocations, and suspensions. All applicable final legal actions must be
reported, regardless of whether any records were expunged or any appeals are pending. See explanation below. List any additional
names and addresses on the proper section of the sheet provided.
1. Has any individual (s) or organizations listed in this application, under any current or former name or
business identity, within ten years from the date of this statement, ever:
A. Had a final adverse action, conviction, exclusion, revocation or suspension by any state, including the Common
Wealth of Puerto Rico or federal, state or local government program or agency (ex. Medicare, Medicaid, TITLE V
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
or Title XX)?
B. Been convicted of any felony or misdemeanor involving fraud or abuse in any federal, state or local government
program or agency (ex. Medicare, Medicaid, TITLE V or Title XX)?
C. Found liable of fraud or abuse involving any federal, state or local government program or agency (ex. Medicare,
Medicaid, TITLE V or Title XX) in any civil proceeding?
D. Entered into a settlement in lieu of conviction for fraud or abuse involving any federal, state or local government
program or agency (ex. Medicare, Medicaid, TITLE V or Title XX)?
E. Had your license, certificate or other approval to provide health care ever been excluded, revoked or suspended,
from a federal, state or local government program or agency (ex. Medicare, Medicaid, Title V or Title XX
Program)?
F. Ever lost or surrendered your license, certificate, or other approval to provide health care, while a disciplinary
hearing was pending?
G. Ever been convicted of any crime (excluding traffic or parking violations) or pending any litigation for an alleged
crime?
H. Ever been convicted of a crime under the Criminal Control Act or are you currently under indictment for an alleged
crime?
I.
Ever lost, revoke or suspend your DEA or AMSSCA license?
J. Has your license, certificate, or other approval to provide health care, ever been disciplined by any licensing
authority?
K. Had your clinical privileges suspended, limited or terminated from any local or federal institution (hospital, health
clinic, other health facility, etc.)?
If you answered “Yes” to any question above, please complete Section 3A.1, then proceed to and all other
questions in section 3.
Full Name of Organization (Legal Business Name) or Full Name of Individual (First and Last Names)
3A.1.
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Provider Application Form- Vision Services
02-2015
PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
Check Applicable Program
State
Medicaid
Medicare
Other: Specify:
____________________
TYPE OF OFFENSE AND DISPOSITION:
EFFECTIVE DATE(S) OF
(Conviction, Exclusion, Revocation or
Suspension)
/ /
/ /
/ /
DATE(s) OF REINSTATEMENT(s) (If
Any)
/
/
/
/
/
/
3A.2 Do you the Applicant/Provider, currently participate or has this entity ever participated, as a provider in a Medicare, Medicaid, TITLE V or
Title XX Program in another state?
Yes
No
If yes, provide information in Section 3A.2.
Full Name of Organization (Legal Business Name) or Full Name of Individual (First and Last Names)
3A.2.
State
Name(s) (Legal and DBA)
NPI and/or Provider Number
Full Name of Organization (Legal Business Name) or Full Name of Individual (First and Last Names)
1. 3A.2.
2.
State
Name(s) (Legal and DBA)
NPI and/or Provider Number
3A.3. List below any fines/debts due and owing to any federal, state or local government program or agency (ex. Medicare, Medicaid, Title V
or Title XX) that have not been paid and what arrangements have been made to fulfill the obligation (s).
Yes
No
If yes, provide information in Section 3A.3
Please list information 3A.3:
If yes, submit copies of all documents pertaining to the arrangements including terms and conditions.
Fine/Debt
Agency
Date Issued
Date to be Paid in Full
$
/
/
/
/
$
/
/
/
/
Address (Street Name or Suite and Number)
Medicare Identification Number
Page 7 of 17
City
State
Tax identification number (Required)
Zip Code
NPI
Provider Application Form- Vision Services
02-2015
PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
SECTION 4. DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST INFORMATION (42 CFR 455.101-455.106; 42 CFR
420.201-420.206) According to the Code of Federal Regulations title 42, part 455, sections 101-106 AND part 420, sections 201-206, all
providers enrolling with Medicaid and Medicare Advantage programs must complete a Provider Disclosure Statement.
ALL PROVIDERS MUST COMPLETE THIS SECTION. Refer to Attachment II for instructions on how to complete this Section.
Check one that most closely describes you:
o Individual
o Group Practice o Disclosing Entity
Name of Individual, Group Practice, or Disclosing Entity
Address
City
Federal Tax Identification Number
NPI
1.
State
Zip Code
Questions 1 -3 to be answered by all providers
Has the provider, or any person who has ownership or control interest in the provider, or is an agent or managing employee
of the provider ever been suspended, excluded, or debarred related to the person's involvement in any program under
Medicare, Medicaid, or the Title XX program or convicted of a crime related to that person's involvement in any program
under Medicare, Medicaid, or the Title XX program? If yes, list the name(s) of person(s). (42 CFR 455.106)(Should be
verified through appropriate HHS-EPLS-OIG website)
NAME
TITLE
ADDRESS
YES o
NO o
DESCRIPTION
A.
B.
C.
D.
2. Has the provider had business transactions with any subcontractor totaling more than $25,000 during the preceding 12-month
period? If yes, give the information below for each subcontractor. (42 CFR 455.105). If response is NO, continue to question #3.
NAME
YES o
NO o
ADDRESS
A.
B.
C.
D.
2a. Provide the name and address of all persons with an ownership or control interest in each subcontractor named in question
#2. NOTE: Designate relationship to subcontractor listed above by using A., B., C., etc. (42 CFR 455.105)
NAME
N/A o
ADDRESS
A.
B.
C.
D.
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Provider Application Form- Vision Services
02-2015
PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
3. Has the provider had any significant business transactions with any wholly owned supplier or with any subcontractor during the
preceding five-year period? If yes, give the information below for each wholly owned supplier or subcontractor. (42 CFR 455.105)
YES o
NO o
NAME
ADDRESS
DESCRIPTION OF BUSINESS TRANSACTION
A.
B.
C.
D.
Questions 4 – 6 to be answered by fiscal agents and by all providers EXCEPT individual practitioners.
4. Provide the name and address of each person with an ownership or control interest in the provider/fiscal agent or in any subcontractor in which the
provider/fiscal agent has direct or indirect ownership of five percent or more. (42 CFR 455.104)
NAME
ADDRESS
A.
B.
C.
D.
5. Is any person named in question #4 related to another as spouse, parent, child, or sibling? If yes, give the name(s) of person(s)
and relationship(s). NOTE: Designate relationship to each person listed in question #4 by using A., B., C., etc. (42 CFR 455.104)
YES o
NO o
NAME
RELATIONSHIP
A.
B.
C.
D.
6. Does any person named in question #4 have an ownership or control interest in any other Medicaid provider or in any entity that
does not participate in Medicaid but is required to disclose certain ownership and control information because of participation in
any of the programs established under Title V, XVIII, or XX of the Act? If yes, give the name(s) of and address(es) of the Medicaid
provider or entity. NOTE: Designate relationship to each person listed in question #4 by using A., B., C., etc. (42 CFR 455.104)
NAME
YES o
NO o
ADDRESS
A.
B.
C.
D.
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement,
may be prosecuted under applicable federal or State laws. In addition, knowingly and willfully failing to fully and
accurately disclose the information requested may result in denial of a request to participate or, where the entity
already participates, a termination of its agreement or contract with the State agency.
Page 9 of 17
Provider Application Form- Vision Services
02-2015
PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
SECTION 5. BILLING INFORMATION- This section captures information on PERSON (INDIVIDUAL) OR BILLING AGENCY that submits
claims on behalf of provider. A Person (individual) or billing agency is a company or individual that you contract with to prepare and submit
your claims. Ultimately, you are responsible for the claims submitted on your behalf.
5A - BILLING PERSON OR AGENCY NAME AND ADDRESS
1. Check One:
Individual (Employee) in Office
Individual not in office
Billing Agency
Sub-Contractor
Other, Specify: ______________________ (If other, is the name of an individual or sub-contractor is checked and it is and
individual, complete area identified as “If Individual in Office or Not in Office”)
5A1 - BILLING AGENCY INFORMATION
2. Legal Business Name (as Reported to Internal Revenue-Hacienda)
4. Billing Agency Address (Street Name and Address)
7. Telephone Number
3. Doing Business As (DBA) name (If applicable)
5. Tax ID Number or Social Security
Number (required)
8. Fax Number (If Applicable)
9. City
Billing Person Date of Birth (mm/dd/yy)
6. E-mail Address (If Applicable)
10. State
11. Zip Code
Social Security Number (required)
5A2 - IF INDIVIDUAL IN OFFICE OR NOT IN OFFICE:
12. Full Name and Title of Individual (include both paternal and
maternal Last names):
15. Address (Street Name and Address)
16. City
13. Telephone Number:
17. State
14. Fax Number:
18. Zip Code
19. Please identify if the individual(s), agency or other, that submits claims on your behalf (Check One):
Also submits for the additional address
Only for primary address
Both primary and additional address
Other Specify: ____________________________________
Page 10 of 17
Provider Application Form- Vision Services
02-2015
PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
SECTION 6. PROVIDER PAYMENT INFORMATION
6A. PROVIDER PAYMENT INFORMATION: Once we have finalized your credentialing process, we would need to know your
payment information in order to have your payments sent to the correct address and payee. It is important to know that in order to
have your checks payable to the Clinic, Center, Group or Corporation, this practice should have their own NPI and Tax
Identification number.
Please provide your Tax Identification Number of Clinic, Center, Group or Corporation, your reporting Name and Address as they
appear on your IRS form W-9. This will ensure that our files contain accurate information for reporting on IRS Form 1099
payments to your organization:
1. List Tax ID number
2. List Medicare Number
3. List NPI number
4. Payee Address Line 1 (Street Name and number):
5. Payee Address Line 2 (Suite or Room):
6. City/Town:
7. State:
8. Zip Code:
9. Telephone Number:
10. Fax Number:
11. Email Address (If Applicable):
12. Are you going to:
rSeparately bill for each department? (If you checked here, answer question 6B and 6C)
r Bill for the entire entity with one billing number? (If marked here, then the Tax ID paid will be as indicated in “List Tax ID number” above)
r Not Applicable
6B - List the departments for which you plan to bill separately (If Applicable):
Department
Medicare Identification
Number
NPI Identification
Number
Tax ID Number (only
applicable, if different as
indicated in the billing)
6C - Comments/ Special Circumstances
Explain any unique circumstances concerning your practice location, the method by which you render health care services, etc.
6D - PROVIDER PAYMENT INFORMATION-AUTHORIZED SIGNATURE: (Authorized or Delegated Official, Please sign below)
Identify Official Signature:
13. First Name
Authorized Official
Delegated Official
14. Middle Initial
15. Last Name
16. Suffix (e.g. Jr. Sr.)
17. Title/ Position
18. Telephone
19. Signature:
20. Date Signed (mm/dd/yyyy)
Page 11 of 17
Provider Application Form- Vision Services
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PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
SECTION 7. – STANDARD AUTHORIZATION, ATTESTATION AND RELEASE OF INFORMATION
REFER TO ATTACHMENT I – LIST OF AUTHORIZED ORGANIZATIONS
An Authorized Official means an appointed official (for example, chief executive officer, chief financial officer, general partner,
chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll, to make changes or
updates to the organization’s status in the Federal, State and/or local programs, and to commit the organization to fully abide by the
statutes, regulations, and program instructions of the Federal, State and/or local programs.
A Delegated Official means an individual who is delegated by an authorized official the authority to report changes and updates to
the supplier’s enrollment record. A delegated official must be an individual with an “ownership or control interest” in (as that term is
defined in Section 1124(a)(3) of the Social Security Act), or be a W-2 managing employee of, the supplier.
Delegated officials may not delegate their authority to any other individual. Only an authorized official may delegate the authority to
make changes and/or updates to the supplier’s status. The provider can have as many authorized officials as it wants. If the provider
has more than two authorized officials, it should copy and complete this section as needed.
By his/her signature(s), an authorized official binds the provider and agrees that, as part of the credentialing application process for
participation, membership and/or clinical privileges (hereinafter, referred to as “Participation”) at or with each healthcare organization
indicated on the “List of Authorized Organizations” that accompanies this Application (hereinafter , each healthcare organization on
the “List of Authorized Organizations” is individually referred to as the “Entity”) and any of the Entity’s affiliated entities, he/she is
required to provide sufficient and accurate information for a proper evaluation of the provider’s current licensure, relevant training
and/or experience, clinical competence, health status, character, ethics, and any other criteria used by the Entity for determining
initial and ongoing eligibility for Participation. Each Entity and its representatives, employees, and agent(s) acknowledge that the
information obtained relating to the application process will be held confidential to the extent permitted by law.
By his/her signature(s), an authorized official binds the provider and acknowledges that each Entity has its own criteria for
acceptance, and the provider may be accepted or rejected by each independently. I further acknowledge and understand that
my cooperation in obtaining information and my consent to the release of information does not guarantee that any Entity will
grant the provider clinical privileges or contract as a provider of services. I understand that the provider’s application for
participation with the Entity is not an application for employment with the Entity and that acceptance of application by the Entity
will not result in the provider’s employment by the Entity.
Authorization of investigation concerning application for participation. By his/her signature(s), an authorized official binds the
provider and authorizes the following individuals including, without limitation, the Entity, its representatives, employees, and/or
designated agents; the entity’s affiliated entities and their representatives, employees and/or designated agents; and the Entity’s
designated professional credentials verification organization (collectively referred to as “Agents”), to investigate information, which
includes both oral and written statements records, and documents, concerning my application for participation. The provider agrees
to allow the Entity and/or its agent(s) to inspect and copy all records and documents relating to such an investigation.
Authorization of third-party sources to release information concerning application for participation. By his/her signature(s),
an authorized official binds the provider and authorizes any third party, including, but not limited to, individuals, agencies, medical
groups responsible for credentials verification, corporations, companies, employers, former employers, hospitals, health plans, health
maintenance organizations, managed care organizations, law enforcement or licensing agencies, insurance companies, educational
and other institutions, military services, medical credentialing and accreditation agencies, professional medical societies, the
Federation of State Medical Boards, the National Practitioner Data Bank, Junta de Licenciamiento y Disciplina Médica de Puerto
Rico, Office of Personnel Management (OPM), and the Office of the Inspector General (OIG), to release to the Entity and/or its
agent(s), information, including otherwise privileged or confidential information, concerning the provider’s professional qualifications,
credentials, clinical competence, quality assurance and utilization data, character, mental condition, physical condition, alcohol or
chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing on the provider’s
qualifications for participation in, or with, the Entity. I authorize the provider’s current and past professional liability carrier(s) to
release history of claims that have been made and/or are currently pending against the provider. I specifically waive written notice
from any entities and individuals who provide information based upon this Authorization, Attestation and Release.
Authorization of release and exchange of disciplinary information. By his/her signature(s), an authorized official binds the
provider and hereby further authorizes any third party at which the provider’s currently have participation or had participation and/or
each party’s agents to release “Disciplinary Information” as defined below, to the Entity and/or its agent(s). I hereby further authorize
the agent(s) to release disciplinary information about any disciplinary action taken against the provider to its participating entities at
which the provider has participation, and as may be otherwise required by law. As used herein, ‘Disciplinary Action” means
information concerning (i) any action taken by such health care organizations, their administrators, or their medical or other
committees to revoke, deny, suspend, restrict, or condition my participation or impose a corrective action plan; (ii) any other
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Provider Application Form- Vision Services
02-2015
PARTICIPATING PROVIDER CREDENTIALING APPLICATION
VISION SERVICES
disciplinary action involving the provider, including, but not limited to, discipline in the employment context; or (iii) the provider’s
resignation prior to the conclusion of any disciplinary proceedings or prior to the commencement of formal charges, but after the
provider have knowledge that such formal charges were being (or are being) contemplated and/or were (or are) in preparation.
Release from liability. By his/her signature(s), an authorized official binds the provider and releases from all liability and hold
harmless any Entity, its agent(s), and any other third party for their acts performed in good faith and without malice unless such acts
are due to the gross negligence or willful misconduct of the Entity, its agent(s), or other third party in connection with the gathering,
release and exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release. The
provider further agrees not to sue any entity, any agent(s), or any other third party for their acts, defamation or any other claims
based on statements made in good faith and without malice or misconduct of such entity, agent(s) or third party in connection with the
credentialing process, This release shall be in addition to, and in no way shall limit, any other applicable immunities provided by law
for peer review and credentialing activities. In this Authorization, Attestation and Release, all references to the entity, its agent(s)
and/or other third party include their respective employees, directors, officers, advisors, counsel and agents. The entity or any of its
affiliates or agents retain the right to allow access to the application information for purposes of a credentialing audit to customers
and/or their auditors to the extent required in connection with an audit of the credentialing processes and provided that the customer
and/or their auditor executes an appropriate confidentiality agreement. I understand and agree that this Authorization, Attestation
and Release is irrevocable for any period during which the provider is an applicant for participation at an entity, a member of an
entity’s medical or health care staff, or a participating provider of an entity. The provider agrees to execute another form of consent if
law or regulation limits the application of this irrevocable authorization. The provider understands that failure to promptly provide
another consent may be grounds for termination or discipline by the entity in accordance with the applicable bylaws, rules, and
regulations, and requirements of the entity, or grounds for my termination of participation at or with the entity. The provider agree that
information obtained in accordance with the provisions of this Authorization, Attestation and Release is not and will not be a violation
of my privacy.
I certify that all information provided by me in my application is current, true, correct, accurate and complete to the best of my
knowledge and belief, and is furnished in good faith.
I will notify the entity and /or its agent(s) within 30 days of any material
changes to the information (including any
changes/challenges to licenses, DEA, insurance, malpractice claims, NPDB/HIPDB
reports, discipline, criminal convictions, etc.) I have provided in my application or authorized to be released pursuant to the
credentialing process.
I understand that corrections to the application are permitted at any time prior to a determination of
participation by the entity of the provider, and must be submitted online or in writing, and must be dated and signed by me (may be a
written or an electronic signature). I acknowledge that the entity will not process an application until they deem it to be a complete
application and that I am responsible to provide a complete application and to produce adequate and timely information for resolving
questions that arise in the application process. I understand and agree that any material misstatement or omission in the application
may constitute grounds for withdrawal of the application from consideration; denial or revocation of participation; and/or immediate
suspension or termination of participation or be subject to applicable state or federal penalties for perjury of the provider. This action
may be disclosed to the entity and/or its agent(s). I further acknowledge that I have read and understand the foregoing Authorization,
Attestation and Release and that I agree to abide by its terms, rules and regulations. I understand and agree that a facsimile or
photocopy of this Authorization, Attestation and Release shall be as effective as the original.
Identify Official Signature:
First Name
Authorized Official
Middle Initial
Delegated Official
Last Name
Suffix (e.g. Jr. Sr.)
Title/ Position
Telephone
Signature:
Date Signed (mm/dd/yyyy)
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SECTION 8. – CERTIFICATION STATEMENT
REFER TO ATTACHMENT I – LIST OF AUTHORIZED ORGANIZATIONS
An Authorized Official means an appointed official (for example, chief executive officer, chief financial officer, general
partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll, to make
changes or updates to the organization’s status in the Federal, State and/or local programs, and to commit the organization
to fully abide by the statutes, regulations, and program instructions of the Federal, State and/or local programs.
A Delegated Official means an individual who is delegated by an authorized official the authority to report changes and
updates to the supplier’s enrollment record. A delegated official must be an individual with an “ownership or control interest”
in (as that term is defined in Section 1124(a)(3) of the Social Security Act), or be a W-2 managing employee of, the supplier.
Delegated officials may not delegate their authority to any other individual. Only an authorized official may delegate the
authority to make changes and/or updates to the supplier’s status. The provider can have as many authorized officials as it
wants. If the provider has more than two authorized officials, it should copy and complete this section as needed.
I, the undersigned, certify to the following:
1. By his/her signature(s), an authorized official binds the provider to all of the requirements listed in the
Certification Statement and acknowledges that the supplier may be denied entry to or revoked from the
Entity, if any requirements are not met.
2.
By signing this application, an authorized official agrees to immediately notify the Entity. if any information
furnished on the application is not true, correct, or complete. In addition, an authorized official, by his/her
signature, agrees to notify the Entity. Immediately, in accordance with the timeframes established and as
stipulated in 42 C.F.R. 424.520(b) and/or 42 C.F.R. 424.516.
3.
I authorize the Entity. to verify the information contained herein. I agree to notify the Entity of a change in
ownership, practice location and/or Final Adverse Action immediately of the reportable event. In addition, I
agree to notify the Entity of any other changes to the information to this form immediately of the effective
date of change. I understand that any change in business structure of this Institution may require the
submission of a new application.
4.
I understand that any deliberate omission, misrepresentation, or falsification of any information contained in
this application or contained in any communication supplying information to Medicare, Medicaid, or any
deliberate alteration of any text on this application form, may be punished by criminal, civil, or administrative
penalties including, but not limited to, the denial or revocation of Medicare, Medicaid billing privileges, and/or
the imposition of fines, civil damages, and/or imprisonment.
5.
I agree to abide by the Medicare laws, regulations and program instructions that apply to me or to the
organization. The Medicare laws, regulations, and program instructions are available through the Entity. I
understand that payment of a claim by Medicare, Medicaid, Title V or Title XX is conditioned upon the claim
and the underlying transaction complying with such laws, regulations, and program instructions (including,
but not limited to, the Federal anti-kickback statute and the Stark law), and on the supplier’s compliance with
all applicable conditions of participation in Medicare, Medicaid, Title V or Title XX program.
6.
Neither I, nor any managing employee listed on this application, is currently sanctioned, suspended,
debarred, or excluded by the Medicare or State Health Care Program, e.g., Medicaid program, or any other
Federal program, or is otherwise prohibited from providing services to Medicare or other Federal program
beneficiaries.
7.
I agree that any existing or future overpayment made to me (or to the organization listed in this application)
may be recouped by the Entity through the withholding of future payments.
8.
I understand that the Entity identification number issued to me can only be used by me or by a provider or
supplier to whom I have reassigned my benefits under current Medicare regulations, when billing for
services rendered by me.
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PARTICIPATING PROVIDER CREDENTIALING APPLICATION
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9.
I will not knowingly present or cause to be presented a false or fraudulent claim for payment by the Entity
and will not submit claims with deliberate ignorance or reckless disregard of their truth or falsity.
10. I further certify that the entity identified on the first page of this application is applying for the Entity
11. I agree to ensure that the disclosing entity must—(i) Keep copies of all these requests and the responses to
them; (ii) Make them available to the Health plan upon request; and (iii) Advise the Medicaid agency when
there is no response to a request.
12. I understand that Federal Financial Participation (FFP) is not available to a provider or fiscal agent that fails
to disclose ownership or control information as required by Medicare, Medicaid, Title V or Title XX Program.
13. I understand that I am responsible for the claims that are submitted on my behalf.
14. If N/A is answered in Billing Section, the supplier, applicant, provider is responsible for all claims submitted
on his/her behalf.
I have read the contents of this application. My signature legally and financially binds this provider to the laws, regulations,
and program instructions of the Medicare, Medicaid, and Local, Title V and/or Title XX programs. By my signature, I certify
that the information contained herein is true, correct, and complete and I authorize the Entity to verify this information. If I
become aware that any information in this application is not true, correct, or complete, I agree to notify the Entity. of this fact
immediately.
Identify Official Signature:
First Name
Authorized Official
Middle Initial
Delegated Official
Last Name
Suffix (e.g. Jr. Sr.)
Title/ Position
Telephone
Signature:
Date Signed (mm/dd/yyyy)
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PARTICIPATING PROVIDER CREDENTIALING APPLICATION
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ATTACHMENT I
LIST OF AUTHORIZED ORGANIZATIONS
TRIPLE-S SALUD, INC,
TRIPLE S- ADVANTAGE, INC.
TRIPLE S- ADVANTAGE SOLUTIONS, INC.
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ATTACHMENT II
INSTRUCTIONS FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST
(42 CFR 455.101-455.106; 42 CFR 420.201-420.206)
According to the Code of Federal Regulations title 42, part 455, sections 101-106 AND part 420, sections 201-206, all providers
enrolling with Medicaid and Medicare Advantage programs must complete a Provider Disclosure
Statement. The definitions below are designed to clarify certain questions on the Disclosure form. If you cannot report all of the
necessary information in a designated section of the form because of space limitations, please provide the information on a
separate paper. Definitions Agent means any person who has been delegated the authority to obligate or act on behalf of a
provider. Disclosing entity means a Medicaid provider (other than an individual practitioner or group of practitioners), or a fiscal
agent.
Any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of
participation in any of the programs established under title V, XVIII, or XX of the Act. This includes:
(a) Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health
clinic, or health maintenance organization that participates in Medicare (title XVIII);(b) Any Medicare intermediary or carrier; and
(c) Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, healthrelated services for which it claims payment under any plan or program established under title V or title XX of the Act.
Fiscal agent means a contractor that processes or pays vendor claims on behalf of the Medicaid agency.
Group of practitioners means two or more health care practitioners who practice their profession at a common location (whether or
not they share common facilities, common supporting staff, or common equipment).
Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This
term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.
Individual practitioner means a physician or other licensed or certified under State law to practice his or her profession.
Managing employee means a general manager, business manager, administrator, director, or other individual who exercises
operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution,
organization, or agency.
Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity.
Person with an ownership or control interest means a person or corporation that—
(a) Has an ownership interest totaling 5 percent or more in a disclosing entity; (b) Has an indirect ownership interest equal to 5
percent or more in a disclosing entity; (c) Has a combination of direct and indirect ownership interests equal to 5 percent or more
in a disclosing entity; (d) Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by
the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity; (e) Is an
officer or director of a disclosing entity that is organized as a corporation; or (f) is a partner in a disclosing entity that is organized
as a partnership.
Significant business transaction means any business transaction or series of transactions that, during any one fiscal year, exceed
the lesser of $25,000 and 5 percent of a provider's total operating expenses.
Subcontractor means— (a) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of
its management functions or responsibilities of providing medical care to its patients; or
(b) An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or
lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement.
Supplier means an individual, agency, or organization from which a provider purchases goods and services used in carrying out
its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical firm).
Wholly owned supplier means a supplier whose total ownership interest is held by a provider or by a person, persons, or other
entity with an ownership or control interest in a provider.
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