Organizational Provider Credentialing Application Instructions: Please complete the following application. Additionally, the following documents, where applicable, will be required: Facility license Facility administrator’s license Director of nursing’s license Current copy of your Professional Liability Insurance Face Sheet (limit at a minimum of $1M / $3M) Copy of W-9 for each Tax ID number with which you bill. Recredentialing Facility profile corrected and initialed (please initial even if no change is made) Certified Laboratory Improvement Amendments (CLIA) certification Most recent CMS survey, including corrective action plan if deficiencies were cited and evidence from CMS that all deficiencies are remedied. Most recent Department of Health Facility Regulation on-site survey, including corrective action plan if deficiencies were cited and evidence that all deficiencies have been remedied. Copy of Accreditation certification (Neighborhood will conduct a site visit at facilities not accredited by an accrediting agency accepted by Neighborhood) If you have any questions regarding this application, please call Neighborhood’s Credentialing Department at (401) 459-6000. Please complete each section. Clearly state if information requested is not applicable. Type of Facility*Adult Day CareAssisted LivingDialysis Center/ClinicAmbulatory Surgical CenterHome Health Agency/HospiceHospitalLaboratorySkilled Nursing FacilityHome InfusionFacility DemographicsLegal Business Name* Doing Business As (DBA) Name If applicableAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxEmail* Enter Email Confirm Email Credentialing ContactName* First Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxEmail* Enter Email Confirm Email Billing InformationContact Name* First Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxEmail* Enter Email Confirm Email Agencies providing skilled servicesDirector of Nursing: Name First Last Director of Nursing: State License #* Please attach a copy of the Director of Nursing’s license.Accepted file types: pdf, Max. file size: 2 MB.Skilled Nursing Facility**A Medical Director who does not have a current application with CAQH must submit Neighborhood’s application for credentialing and/or recredentialing. Medical Director: Name First Last Medical Director: CAQH ID #* Please attach a copy of the Medical Director’s license.Accepted file types: pdf, Max. file size: 2 MB. For initial credentialing, please provide information pertaining to the past 10 years. For Re-credentialing, please provide information pertaining to the past 3 years. If the answer is “YES” to any of the question below (with exception of questions 1, 2a, 3a, 12 & 13), you must submit explanation as part of this application. Facility/Administrator: 1. Is this facility participating in the Medicare/Medicaid program (CMS)*1. Is this facility participating in the Medicare/Medicaid program (CMS) *YesNo2. Has this facility had an initial on-site survey by CMS?*2. Has this facility had an initial on-site survey by CMS? *YesNo2a. If yes, date of most recent full onsite survey by CMS* MM slash DD slash YYYY 2b. Were any deficiencies identified during the on-site survey?*2b. Were any deficiencies identified during the on-site survey? *YesNoIf yes, provide evidence of acceptance of the Corrective Action Plan*Accepted file types: docx, pdf, Max. file size: 2 MB.3. Has this facility had an initial on-site survey by the Department of Health Facility Regulation (DOH)?*3. Has this facility had an initial on-site survey by the Department of Health Facility Regulation (DOH)? *YesNo3a. If yes, date of most recent full onsite survey by DOH* MM slash DD slash YYYY 3b. Were any deficiencies identified during the on-site survey?*3b. Were any deficiencies identified during the on-site survey? *YesNoIf yes, provide evidence of acceptance of the Corrective Action Plan*Accepted file types: docx, pdf, Max. file size: 2 MB.4. Has any formal complaint been filed with CMS?*4. Has any formal complaint been filed with CMS? *YesNo5. Has any formal complaint been filed with DOH?*5. Has any formal complaint been filed with DOH? *YesNo6. Is the facility currently on any Corrective Action Plan with any Board of Facility Regulation, CMS or any other organization?*6. Is the facility currently on any Corrective Action Plan with any Board of Facility Regulation, CMS or any other organization? *YesNo7. Has any professional or general liability lawsuits been filed, settled and/or adjudicated or is currently pending against the facility?*7. Has any professional or general liability lawsuits been filed, settled and/or adjudicated or is currently pending against the facility? *YesNo8. Has the liability insurance coverage been cancelled, denied or modified (e.g. reduced limits, restricted coverage), denied renewal or surcharge applied?*8. Has the liability insurance coverage been cancelled, denied or modified (e.g. reduced limits, restricted coverage), denied renewal or surcharge applied? *YesNo9. Has the facility ever been required or agreed to pay civil monetary penalties under Medicare or Medicaid or otherwise sanctioned by CMS?*9. Has the facility ever been required or agreed to pay civil monetary penalties under Medicare or Medicaid or otherwise sanctioned by CMS? *YesNo10. Has any Federal or State agency ever taken any action which limited this facility?*10. Has any Federal or State agency ever taken any action which limited this facility? *YesNo11. Has the facility’ ever voluntarily surrendered or had your license refused, restricted, suspended or revoked in any state?*11. Has the facility’ ever voluntarily surrendered or had your license refused, restricted, suspended or revoked in any state? *YesNo12. Is criminal background check performed for all personnel employed by the facility?*12. Is criminal background check performed for all personnel employed by the facility? *YesNo13. Does the facility conduct ongoing screening and monitoring to ensure all personnel employed and vendors the provider contracts with are not excluded from Medicare and/or Medicaid program?*13. Does the facility conduct ongoing screening and monitoring to ensure all personnel employed and vendors the provider contracts with are not excluded from Medicare and/or Medicaid program? *YesNo14. Have any formal or written claims alleging malpractice been opened, pending or resolved against this facility?*14. Have any formal or written claims alleging malpractice been opened, pending or resolved against this facility? *YesNoCarrier at Time of Incident* Date of Alleged Incident* MM slash DD slash YYYY Date of Lawsuit Filed* MM slash DD slash YYYY Name of Court* Case Number* Date of Settlement MM slash DD slash YYYY Status of Case (with reference to you specifically)* Notice of Claim Filed Pending Before Malpractice Panel Pending in Court Closed Without Payment Pre-Trial Settlement Verdict for Defendant Verdict for Plaintiff Pre-Trial Settlement - Dollar Amount* Verdict for Plaintiff - Dollar Amount* What was/is your status?* Sole-defendant Co-Defendant Other Co-Defendant: Further Explanation* Other: Further Explanation* I certify that I am the duly authorized representative of the Facility, that all information provided herein, including attachments, represents full and truthful disclosures of the matters to which they pertain. Name of person who completed the questionnaire* First Last Title* Signature*Date* MM slash DD slash YYYY Facility License*Accepted file types: pdf, Max. file size: 2 MB.W-9*Accepted file types: pdf, Max. file size: 2 MB.Current Professional Liability Insurance Face Sheet*Accepted file types: pdf, Max. file size: 2 MB.Certified Laboratory Improvement Amendments (CLIA) certificationAccepted file types: pdf, Max. file size: 2 MB.Most recent CMS survey, including corrective action plan if deficiencies were cited and evidence from CMS that all deficiencies are remediedAccepted file types: pdf, Max. file size: 2 MB.Most recent Department of Health Facility Regulation on-site survey, including corrective action plan if deficiencies were cited and evidence that all deficiencies have been remediedAccepted file types: pdf, Max. file size: 2 MB.Copy of Accreditation certification (Neighborhood will conduct a site visit at facilities not accredited by an accrediting agency accepted by Neighborhood)Accepted file types: pdf, Max. file size: 2 MB.CAPTCHA