Practitioner Credentialing Application 12.18...Completed Background Check Authorization Form....

CREDENTIALING APPLICATION TO

PARTICIPATE AS A HEALTH CARE

PRACTITIONER

Please submit application to:

[email protected]

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Credentialing Application to Participate as Health Care Practitioner

INSTRUCTIONS

A Licensed Practitioner must apply for and be credentialed with Trillium Health Resources to qualify for reimbursement of services provided to Trillium Health Resources members. Additionally, Practitioners must have a signed contract with Trillium Health Resources or be employed by an Organization or Group Practice that has a signed contract with Trillium Health Resources to qualify for reimbursement of services provided to Trillium Health Resources members.

THE CREDENTIALING PROCESS INCLUDES THE FOLLOWING STEPS: 1. Provider completes and signs the Credentialing Application and returns it along with the required

documentation to [email protected]

2. A Credential Application is considered to be invalid and must be returned to the provider for correctionand/or for additional information if:

All spaces in the application have not been completed. Must put N/A or Not Applicable

The Signatures, where required, are not original and dated within 180 days.

The Signatures are not by the individual applicant.

The text has been altered, highlighted, struck through, or obstructed through the use of correction fluids.

The responses are illegible.

The National Provider Identifier is not a valid number.

Any of the documents or pages that comprise the Credentialing Application are missing.

Any requested information in any of the documents that comprise the application are missing.

NC Tracks enrollment is incomplete or missing service location, accreditation, taxonomy, or affiliations,

as required.

CHECKLIST - Before submitting the Credentialing Application, ensure the necessary components are

included in the following order:

Current Valid Enrollment with NC Tracks to include all of the clinician’s service site locations.

Copy of the Certificate of Insurance for your current professional liability, with coverage amounts of $1,000,000 / $3,000,000 aggregate, effective date, expiration date, and policy number. Completed, signed and dated, included Waiver regarding Auto Insurance Coverage form. Licensed Practitioners who certify in writing that they do not transport clients shall not be required to obtain Automobile Liability Insurance. Licensed Practitioners who do not employ any staff shall not be required to obtain Worker’s Compensation or Employer’s Liability Insurance.

Completed Background Check Authorization Form.

Letter(s) of reference or recommendation, and/or oversight, if required (Practitioner Evaluation Forms

included in this packet). Minimum of two (2) references. Must be dated within the past 180 days. At least

one of the references needs to come from a Peer-Licensed Practitioner, Supervisor, Chief of

Department/Staff where practitioner has admitting privileges and Referring Physician or Practitioner.

Trillium Health Resources reserves the right to contact at least one (1) reference. Note: If provisionally

licensed, one of the references must come from your clinical supervisor.

Copy of the practitioner’s original state(s) license(s) and current registration. If provisionally licensed, submit a current copy of your supervision contract and complete the clinical supervisor information on Item 54 of Section 1 of application.

Copy of current Federal DEA certificate (for MDs/DOs, Physician Assistants and Psychiatric Nurse Practitioners). The Certificate must have a valid date and refer to current address.

Copy of certificate from the Specialty Board, if applicable.

Physicians who are not “Board Certified” must provide an official certified copy of educational transcripts from highest level of education.

Copy of Educational Commission of Foreign Medical Graduate Certificate-ECFMG, if applicable.

Copy of Curriculum Vitae or work history after graduation from Medical, Dental or other professional school.

ADDITIONAL CHECKLIST - For Licensed Independent Practitioners ONLY:

Trading Partner Agreement

Provider Direct System Administrator Form

EFT Authorization with Voided Check or Bank letter & W-9

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Date of

Application:

Independent Licensed

Practitioner

Supplemental Licensed

Practitioner for Agency/Group

1. Name of Applicant:

Last Name First Name Middle Name Maiden

2. List All Current Credentials:

3. Date of Birth: 4. Race/Ethnicity:

5. Social Security Number: 6. Sex:

7. NPI: 8. Taxonomy:

9. Type of Practice: 10. Specialty:

11. What population(s) do you treat (e.g., geriatric, all ages)?

12. Language(s) Proficiently Spoken, including sign

language: Are interpreters available:

Yes No

13. Name of Practice:

14. Main Service Location

Address:

Street City State Zip+4

County: Phone #: Fax #:

Site NPI (Attach copy to application): Email:

Site Taxonomy:

Is this a registered business with Secretary of State? Yes No

Accepting New Referrals: Yes No Restrictions:

Handicapped accessible: Yes No

If no, explain how you would accommodate members with physical disabilities:

Days/Hours of Operation: Do you provide services in the community?

Yes No

15. Billing Information (Only applicable if applicant is approved for a contract with Trillium Health Resources.)

Enter information to be used for submitting claims: N/A

Name(if different from practice name): Federal Tax ID #/SSN:

Billing Address:


SECTION 1: DEMOGRAPHIC AND PERSONAL DATA

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Additional Office:

Address:


Site NPI: Site Taxonomy:

Phone #: Fax #: Email:

Days/Hours of Operation:



Additional Office:

Address:







Additional Office:

Address:







Additional Office:

Address:







SECTION 1: DEMOGRAPHIC AND PERSONAL DATA Continued

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16. Administrative Contact: Title:

Address:



17. Specify the arrangements for 24 hour/7 day coverage apart from and in addition to Community Emergency Response Services (i.e. 911, Emergency Department, Mobile Crisis, etc.):

18. Name and address of practitioner(s) who share call with you.

Practitioners must have similar license or higher and be actively credentialed with Trillium Health Resources.

Name: License:

Address:


Name: License:

Address:


19. Are you currently affiliated with another agency or practice? Yes No

(if so, please list the name of the agency):

Agency Name: Start Date:



20. DEA # (Attach copy to application): Exp. Date:

21. Provide the following information for each state in which you are currently or were previously licensed to practice (if necessary, please attach additional sheet):

StateDate of License

License Number License TypeStatus:

Active, Inactive, Suspended

Expiration Date

****PLEASE ATTACH A COPY OF EACH STATE LICENSE CERTIFICATE****

22. If provisionally licensed, provide a copy of your current supervision contract and the name and contact

information for your clinical supervisor:

Clinical Supervisor:

Address:


Phone #: Email:


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23. Certification of Specialty Boards as applicable: N/A

If you are certified by a specialty board, indicate name of board and date of certificate.

Primary Specialty Board: Date Certified

Expiration Date

Secondary Specialty Board: Date Certified

Expiration Date

Are you listed in the American Board of Medical Specialists? Yes No

If you have applied to a specialty board for examination, give the name of board and the date of the

scheduled examination:

Specialty Board Name: Date:

If you have not applied to a specialty board, please explain:

24. List the dates of all current professional memberships in societies, including state and county

societies:

Professional Membership From (Month/Year) To (Month/Year)

N/A

25. List all hospitals where you currently have privileges and indicate the type and status of those privileges

(physicians only, if Not Applicable please indicate):

Hospital: Estimated % of Admissions:

Privilege and Status of Privilege:

Primary Admitting Facility: Estimated % of Admissions:

Privilege and Status of Privilege:

If you do not have admitting privileges, who admits for you (physicians only): (Attach a copy of your

Admitting Plan)

Name of Admitting Individual:

Address:


Phone #: Email:


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1. Medical, Dental or other Professional School Attended (“See Resume” is not acceptable.):

Institution:

Address:

Street City State Zip

Degree: Date From: Date To:

Name as it appears on degree:

Please attach Educational Commission of Foreign Medical Graduate Certificate – (ECFMG) if applicable.

2. Internship: Institution:

Address:


Specialty: Date From: Date To:

2. Residency: Institution:

Address:



2. Other Residency/Fellowship (specify): Institution:

Address:



5. List work history since beginning of medical, dental or other professional school (last five [5] years) and

explain any employment gaps longer than 6 months; please be specific:

(“See Resume” is not acceptable.) (if necessary, please attach additional sheet)

Practice Name From

(Month/Year)To

(Month/Year)

Current Practice:

Current Practice:

Previous Practice:

Previous Practice:

Previous Practice:

Previous Practice:

6. List other training and/or education (including CME) within the last five (5) years:

7. Have you involuntarily or voluntarily withdrawn, or been suspended from any internship, residency or

fellowship training program (Please explain):

8. Please explain any incident(s) in which you have involuntarily or voluntarily withdrawn your application for

appointment, clinical privileges or reappointment before a decision was made by a hospital or healthcare

facility’s governing board:

SECTION 2: EDUCATION PRACTICE HISTORY

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Please check (√) yes or no for the following questions. If your answer to any of the following questions is “yes”, provide details as specified on

the Supplemental Form. This section must be completed and signed by the practitioner to be accepted.

A. PROFESSIONAL SANCTIONS

1. Have you ever been, or are you now in the process of being denied, revoked, terminated, suspended, restricted, reduced, limited, sanctioned, placed on probation, monitored, or not renewed for any of the following? Or have you voluntarily or involuntarily surrendered, relinquished, withdrawn, or failed to proceed with an application for any of the following in order to avoid an adverse action or to preclude an investigation or while under investigation relating to professional competence or conduct? Or currently under investigation?

a. License to practice any profession in any jurisdiction Yes No

b. Other professional registration or certification in any jurisdiction Yes No

c. Specialty or subspecialty board certification Yes No

d. Membership on any hospital medical staff Yes No

e. Clinical privileges at any facility, including hospitals, ambulatory surgical centers, skilled nursing facilities, etc. Yes No

f.Medicare, Medicaid, FDA, NIH (Office of Human Research Protection), governmental, national or international regulatory agency or any public program Yes No

g. Professional society membership or fellowship Yes No

h. Participation/membership in an HMO, PPO, IPA, PHO, Health Plan or other entity Yes No

i. Academic Appointment Yes No

j. Authority to prescribe controlled substances (DEA or other authority) Yes No

k. Professional employment Yes No

2. Have you ever been subject to review, challenges, and/or disciplinary action, formal or informal, by an ethics committee, licensing board, medical disciplinary board, professional association or education/training institution? Yes No

3. Have you been found by a state professional disciplinary board to have committed unprofessional conduct as defined in applicable state provisions? Yes No

4. To your knowledge, have you ever been reported to the National Practitioner Data Bank or the North/South Carolina Board of Medical Examiners? (if applicable attach copy of NPBD report) Yes No

B. CRIMINAL HISTORY

1. Have you ever been charged with a criminal violation (felony or misdemeanor) resulting in either a plea bargain, conviction on the original or lesser charge, or payment of a fine, suspended sentence, community service or other obligation? Or do you have notice of any such anticipated charges? Are you currently under governmental investigation?

Yes No

C. AFFIRMATION OF ABILITIES

1. Do you presently use any drugs illegally? Yes No

2. Do you have, or have you had in the last five years, any medical, physical, mental health, or chemical dependency condition (alcohol or other substance) that affects or will affect your current ability to practice with or without reasonable accommodation? If reasonable accommodation is required, specify the accommodations required. If the answer to this question is yes, please identify and describe any rehabilitation program in which you are or were enrolled which assures your ability to adhere to prevailing standards of professional performance.

Yes No

3. Are you unable to perform any of the services/clinical privileges required by the applicable participating practitioner agreement/hospital agreement, with or without reasonable accommodation, according to accepted standards of professional performance?

Yes No

D. LITIGATION AND MALPRACTICE COVERAGE HISTORY

1. Have allegations or claims of professional negligence been made against you at any time, whether or not you were individually named in the claim or lawsuit? Yes No

2. Have you or your insurance carrier(s) ever paid any money on your behalf to settle/resolve a professional malpractice claim (not necessarily a lawsuit) and/or to satisfy a judgement (court-ordered damage award) in a professional lawsuit? Yes No

3. Are there any such claims being asserted against you now? Yes No

4. Have you ever been denied professional liability coverage or has your coverage ever been terminated, not renewed, restricted, or modified (e.g. reduced limits, restricted coverage, surcharged)? Yes No

5. Are any of the privileges that you are requesting not covered by your current malpractice coverage? Yes No

6. Have you ever practiced without liability coverage? Yes No

Signature Date

SECTION 3: PRACTITIONER ATTESTATION QUESTIONS

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SECTION 3: PRACTITIONER ATTESTATION QUESTIONS - SUPPLEMENTAL FORM

N/A – No Supplemental Information Needed

All spaces in the application must be completed. Additional pages can be attached in necessary. (Please indicate

“N/A” or “None”, if the question is not applicable)

Applicant Name:

A. PROFESSIONAL SANCTIONS:

List State(s) where action took place: Date(s) of action:

Please explain:

B. CRIMINAL HISTORY:

Did you serve a sentence: Yes No

If Yes, please check (√) how many years. 1 2 3 4 5 6 Other:

List State(s) where action took place: Date(s) of action:

Please explain charge and verdict:

C. AFFIRMATION OF ABILITIES:

Please explain:

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SECTION 3: PRACTITIONER ATTESTATION QUESTIONS - SUPPLEMENTAL FORM Continued

D. LITIGATION AND MALPRACTICE COVERAGE HISTORY:

Please list any past or current professional liability claim(s) or lawsuit(s), in which allegations of professional

negligence were made against you, whether or not you were individually named in the claim or lawsuit. Please do

not include patient names or other HIPAA protected PHI. Photocopy this page as needed and submit a separate

page for EACH claim/event. A legible signed practitioner narrative that addresses all of the following details is an

acceptable alternative.

Date and clinical details of the incident, with preceding events:

Your role and specific responsibility in the incident:

Subsequent events, including patient’s clinical outcome:

Date suit or claim was filed:

Name and Address of Insurance Carrier that handled the claim:

Your status in the legal action (primary defendant, co-defendant, other):

Current status of suit or other action:

Date of settlement, judgment, or dismissal:

If case was settled out-of-court, or with a judgment, settlement amount attributed to you?

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1. Do you have ownership or control interest of 5% or more in this

organization? Yes No

If yes, List all partners, managing employees and Electronic Funds Transfer (EFT) authorized individuals associated with your practice, and provide the information requested on each.

Name: Address:

Title: SSN: License #:

Date of birth: % Owner:

Check business relationship that applies:

Owner Shareholder Partner Manager EFT Auth Staff

Check relationship to enrolling practitioner (if applicable).

Spouse Parent Child Sibling

Name: Address:







Name: Address:







Name: Address:







SECTION 4: OWNERSHIP INFORMATION

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2. Do you have ownership or control interest of 5% or more in other organizations that

bills Medicaid for services? Yes No

If yes, please fill in the following for each organization:

Organization Legal Business Name:

Employer ID #:

National Provider Identifier (NPI) #:


Employer ID #:



Employer ID #:



Employer ID #:



Employer ID #:



Employer ID #:



Employer ID #:



Employer ID #:


SECTION 4: OWNERSHIP INFORMATION Continued

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INSURANCE REQUIREMENTS AND ATTESTATIONS LICENSED INDEPENDENT PRACTITIONERS CONTRACTOR shall purchase and maintain insurance as listed below from a company which is licensed and authorized to do business in the State of North Carolina by the North Carolina Department of Insurance as specified below, unless waived in writing by the LME/MCO.

i. Professional Liability: The CONTRACTOR shall purchase and maintain Professional Liability Insurance protecting the CONTRACTOR and any employee performing work under the Contract for an amount of not less than $1,000,000.00 per occurrence/$3,000,000.00 annual aggregate.

I have provided my Certificate of Insurance showing that I meet this requirement. OR

If I am covered by my employer’s insurance, I have enclosed a statement (either from the employer or an insurance declaration page) that states I am covered.

ii. Comprehensive General Liability: If CONTRACTOR owns the building or facility where services are provided under this agreement, the CONTRACTOR shall purchase and maintain Bodily Injury and Property Damage Liability Insurance protecting the CONTRACTOR and any employee performing work under the Contract from claims of Bodily Injury or Property Damage arising from operations under the Contract for an amount of not less than $1,000,000.00 per occurrence/$3,000,000.00 annual aggregate.

I do not own the building/facility where I provide services. OR

I have provided my Certificate of Insurance showing that I meet this requirement. iii. Automobile Liability: If CONTRACTOR transports recipients, the CONTRACTOR shall purchase and maintain

Automobile Bodily Injury and Property Damage Liability Insurance covering all owned, non-owned, and hired automobiles for an amount not less than $500,000.00 each person and $500,0000.00 each occurrence. Policies written on a combined single limit basis shall have a minimum limit of $1,000,000.00.

I do not transport recipients. OR


If I am covered by my employer’s insurance, I have enclosed a statement (either from the employer or an insurance declaration page) that states I am covered.

iv. Workers’ Compensation and Occupational Disease Insurance, Employer’s Liability Insurance: The CONTRACTOR shall purchase and maintain Workers’ Compensation and Occupational Disease Insurance as required by the statutes of the State of North Carolina. The CONTRACTOR shall purchase and maintain Employer’s Liability Insurance for an amount not less than Bodily Injury by Accident $100,000.00 each Accident/ Bodily Injury by Disease $100,000.00 each Employee/Bodily Injury by Disease $500,000.00 Policy Limit. –

Clinicians associated with my practice are independent contractors and I do not have the minimum number of employees that would require me to maintain this coverage. OR


N/A v. Tail Coverage: Liability insurance may be on either an occurrence basis or on a claims-made basis. If the policy is on

a claims-made basis, an extended reporting endorsement (tail coverage) for a period of not less than three (3) years after the end of the contract term, or an agreement to continue liability coverage with a retroactive date on or before the beginning of the contract term, shall also be provided.

CONTRACTOR shall: i. Submit new COIs no later than ten (10) calendar days after the expiration of any listed policy to ensure

documentation of continual coverage; ii. Notify the LME/MCO in writing within two (2) business days of any cancellation or material change in coverage; iii. Provide evidence to the LME/MCO of continual coverage at the levels stated above within seven (7) calendar days

if CONTRACTOR changes insurance carriers during the performance period of the Contract including tail coverage as required for continual coverage; and

iv. Notify the LME/MCO in writing within two (2) business days of knowledge or notice of a claim, suit, criminal or administrative proceeding against CONTRACTOR and/or Practitioner relating to the quality of services provided under this Contract.

CONTRACTOR shall have the right to self-insure provided that CONTRACTOR’s self-insurance program is licensed by the Department of Insurance of the State of North Carolina and has been actuarially determined sufficient currently to pay the insurance limits required in the Contract.

APPLICANT PRINT NAME APPLICANT SIGNATURE

PRACTICE NAME DATE

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CODE OF ETHICS

PREAMBLE

The Trillium Health Resources provider network shall facilitate an open exchange of ideas, share values, goals,

vision, and promote collaboration and mutual accountability among providers. The provider network strives to

achieve best practices to empower members within our community to achieve their personal goals.

Assure that staff adhere to the Code of Ethics

Provide support to other member agencies

Advocate for the further development of resources on a local and state level for members served

PURPOSE OF CODE

Trillium Health Resources supports and encourages a network community which has an expectation that

providers will adhere to the highest ethical standards.

PHILOSOPHY

Trillium Health Resources network providers agree to abide by the Code of Ethics. Member Agencies shall:

Become familiar with and encourage their Board of Directors, Owners, and Agency personnel to

adhere and follow the Code of Ethics

Agree that actions which violate the Code of Ethics would be considered unethical

Agree that a lack of knowledge is not a defense for unethical conduct

Strive to achieve the highest standards of professional conduct

Acknowledge that all member agencies should be committed to best practices in their specific area

through involvement with continued education, provider networking, and review of relevant research

Have an obligation to report in writing to the LME/MCO any direct knowledge of perceived violations of

the Code of Ethics.

Offer age appropriate services which promote dignity and empower the individual

Reflect the beliefs, values, heritage, and customs of individuals supported by offering culturally

competent services

CORE VALUES AND ETHICAL PRINCIPLES

The mission of the Trillium Health Resources provider network is founded in a set of core values. Network

providers embrace the core values; which serve as the foundation of the provider network. The principles set

forth ideals to which all network providers should aspire.

VALUE: INTEGRITY

ETHICAL PRINCIPLE: Provide accurate and truthful representation.

Network providers will not knowingly permit anyone under their supervision to engage in any practice

that violates the Code of Ethics.

Network providers will not engage in dishonesty, fraud, deceit, misrepresentation of themselves or other

providers, or any form of conduct that adversely reflects on their profession, the provider network, or on

the network providers ability to support members professionally.

Network providers will not commit unethical practices that include, but are not limited to, deceptive

billing, falsification of documentation, commission of a felony, gross neglect and fiduciary impropriety.

VALUE: COMPETENCE

ETHICAL PRINCIPLE: Honor responsibilities to achieve and maintain the highest level of professional competence

for themselves and those in their employ.

Network providers will represent their competence within their scope of practice.

Network providers will engage in only those aspects of the profession, that are within the scope of their

competence, considering their level of education, training, and experience.

Network providers will allow individual staff to provide only those services that are within the staff

member's competence, considering the employee's level of education, training, and experience.

Network provider agencies will demonstrate compliance with state and federal rules, regulations and

laws regarding standards for training and credentials for supports provided.

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VALUE: PROFESSIONAL CONDUCT

ETHICAL PRINCIPLE: Promote dignity and autonomy. Maintain collaborative relationships. All professional

relationships should be directed to improving the quality of life of the individuals who receive supports and

services from the network agency.

Network providers will not participate in activities that produce a benefit for themselves over the

individuals they support or may potentially support, always giving priority to professional responsibility

over any personal interest or gain.

Network providers will make all reasonable efforts to prevent any incidents of abuse, neglect and

exploitation.

Abuse means the infliction of mental or physical pain or injury by other than accidental means, or

unreasonable confinement, or deprivation by an employee of services, which are necessary to the

mental or physical health of the individual. Temporary discomfort that is a part of an approved and

documented treatment plan or use of a documented emergency procedure shall not be considered

abuse.

Neglect means the failure to provide care or services necessary to maintain the mental or physical

health and well-being of the individual.

Network providers will promptly report and thoroughly investigate all allegations of abuse, neglect, and

exploitation.

Under no circumstance will the support relationship between the program, staff, and individuals

receiving services, and/or their families or legal guardian be exploited.

Exploitation is defined as the illegal or unauthorized use of a service user or a service user's resources for

another person's profit, business or advantage.

Network providers will train staff to recognize and report any suspected incidents of abuse and neglect

and exploitation.

VALUE: INDIVIDUAL VALUE, DIGNITY, AND DIVERSITY

ETHICAL PRINCIPLE: Provide supports and services, which promote respect and dignity of each individual

served.

Network providers will comply with all Federal and State rules and laws related to confidentiality and

protected health information, including but not limited to, N.C.G.S. 122C; HIPAA; and the TRILLIUM

HEALTH RESOURCES contract.

Network providers will not discriminate in their relationships or services provided to individuals receiving

supports, contractors, and colleagues on the basis of race or ethnicity, gender, age, religion, national

origin, sexual orientation, or disability.

Network providers will provide individuals and families a means of submitting grievances that is fair and

impartial.

Network providers will comply with N.C.G.S.35A-1201, which allows for all people to be involved in

decisions and choices that impact their lives.

Network providers will make all reasonable efforts to ensure individuals and families participate in the

development and revision of any plan for services.

Network providers will not abandon individuals and families.

Network providers will consistently demonstrate efforts to assure that their services eliminate the effects

of any biases based upon individual and cultural factors.

Network providers will support the recovery and self-determination of each individual.

VALUE: SOCIAL JUSTICE

ETHICAL PRINCIPLE: Assure the rights of individuals receiving supports and others who make decisions regarding

services have complete information on which to make their choices.

Network providers will accurately portray their services and capacities through public and private

statements.

Network providers will not engage in false and deceptive representation of their services.

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Network provider's marketing strategies will not offer inducements to primary individuals receiving

supports or their legal representatives in exchange for business gained.

Network providers will accurately portray their ownership, Board of Directors and management through

public and private statements.

Network providers will follow required laws and standards regarding the hiring of staff.

Network providers will not make initial contact with employees of other providers for the purpose of

offering employment to that individual employee for the purpose of gaining clients. This does not

preclude the individual client to make a choice.

Network providers will use the standards means of advertising for hiring staff.

VALUE: SOCIAL CAPITAL

ETHICAL PRINCIPLE: Network providers support the importance of social capital for each individual supported.

Network providers will support and promote opportunities for individuals they support to develop valued

relationships with members of the community in which they live or work.

Network providers will support and promote opportunities for individuals they support they be treated

with respect and dignity within the community they live or work.

Network providers will support and promote opportunities for individuals they support developing roles in

the community in which they live or work.

Network providers will discuss known violations of standard ethical practices by members with the

offending colleague or agency director. In the event that this does not end in resolution of the issue, the

member shall make a formal complaint to the LME.

VALUE: PARTNERSHIP

ETHICAL PRINCIPLE: Network providers will work together in partnership to develop and achieve individual

desired outcomes.

Network providers will work in partnership:

o To assure continuity of care for members, and

o To assure linkage for services, and

o With members, stakeholders, parents, significant others, and TRILLIUM HEALTH RESOURCES to

support the attainment of each individual's goals.

o Network Providers shall collaborate to share resources that enhance the functions of the

Network to develop solutions for gaps in services.

Approved by:

By signing below, I am attesting that I have read, understand and agree to comply with Trillium Health

Resources "Provider Network Code of Ethics".

Practitioner's Signature Date

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BACKGROUND CHECK AUTHORIZATION FORM

Name: Previous Name: First Middle Last

Current Address: Street City State Zip Code

Number of years are residence?

1st Previous Address: Street City State Zip Code


2nd Previous Address: Street City State Zip Code


Social Security Number: Date of Birth:

Driver's License # and State Issued:

Email Address: (may be used for official correspondence)

Consumer Disclosure I understand that Trillium Health Resources may rely on one or more consumer reporting agencies such as IntelliCorp, Inc. to obtain a consumer report(s) or investigative consumer report(s) (criminal background check, Databank, etc.) for credentialing purposes and I attest that all personal data provided is true, accurate, and complete.

Applicant Authorization I hereby authorize Trillium Health Resources to obtain and rely upon consumer reports or investigative consumer reports for the purpose of credentialing.

Applicant's Signature Date

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ATTESTATION STATEMENT

I certify the information submitted in this entire application, as well as any attachments or supplemental information, is complete, accurate, and current to my best knowledge and belief as of the date of signature below. I fully understand that any misstatements in or omissions from this application may constitute cause for denial of membership or termination of a resulting participation agreement. A photocopy of this application has the same force and effect as the original.

By application for membership in Trillium Health Resources, I signify my willingness to appear for interview in regard to my application. I authorize Trillium Health Resources to consult with administrators and members of the medical staffs of hospitals or institutions with which I have been associated and with others, including past and present malpractice carriers, who may have information bearing on the questions in this application. Upon request, I will obtain and provide to Trillium Health Resources materials pertaining to my qualifications and competence, including, materials relating to complaints filed, any disciplinary action, suspension, or action to curtail my medical- surgical privileges. I further consent to the inspection by representatives of Trillium Health Resources of all documents that may be material to an evaluation of my professional qualifications and competence.

I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubt about such qualifications. I release from liability all representatives of Trillium Health Resources for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I release from any liability, all individuals and organizations that provide information to Trillium Health Resources in good faith and without malice concerning this application and I hereby consent to the release and verification of information relating to any disciplinary action, suspension, or curtailment of medical-surgical privileges to Trillium Health Resources.

I understand that if my application is rejected for reasons relating to my professional conduct or competence, Trillium Health Resources may report the rejection to the appropriate state licensing board and/or National Practitioner Data Bank. In the event I am accepted for participation in Trillium Health Resources Network, I hereby consent to Trillium Health Resources for inspection of my patient records relating to Trillium Health Resources enrollees as necessary for its peer and utilization review purposes as permitted by state or federal law and regulation. I further agree to notify Trillium Health Resources in a timely manner (not to exceed 30 days) of any changes to the information requested on the initial application.

PRINT NAME OF PRACTITIONER SIGNATURE OF PRACTITIONER

DATE

PLEASE SIGN AND DATE THIS ATTESTATION STATEMENT


Practitioner Credentialing Application 12.18...Completed Background Check Authorization Form....

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Transcript of Practitioner Credentialing Application 12.18...Completed Background Check Authorization Form....