The Mississippi Participating Application form is a crucial document for physicians seeking to join a managed care entity in Mississippi. This application collects essential information about a physician's practice, education, licensure, and work history. Completing this form accurately is vital for ensuring compliance and facilitating the application process.
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The Mississippi Participating Application form serves as a crucial document for physicians seeking to join a managed care entity in Mississippi. This comprehensive application requires physicians to provide detailed information about their practice, educational background, licensure, and work history. It is designed to ensure that all applicants meet the necessary qualifications and standards to deliver quality healthcare services. The form is divided into several sections, starting with personal identifying information, including the applicant's name, contact details, and citizenship status. Physicians must also disclose their practice information, including the names and addresses of their primary and secondary offices, as well as any affiliations with medical groups or organizations. The application further requires documentation such as state medical licenses, liability insurance, and proof of board certification, if applicable. Additionally, it addresses the physician's practice capabilities, including the acceptance of new patients, office hours, and any special services offered. By meticulously completing this form, physicians can facilitate their participation in managed care networks, ultimately enhancing their ability to serve patients effectively.
Filling out the Mississippi Participating Application form can be a straightforward process, but several common mistakes can lead to delays or issues. One frequent error is failing to type or print the application clearly in black ink. This requirement is crucial for ensuring that all information is legible. If the application is difficult to read, it may result in processing delays.
Another mistake often made is the use of abbreviations. The instructions explicitly state to avoid abbreviations when completing the application. Using them can lead to misunderstandings or incomplete information, which may hinder the application process.
Some applicants overlook the need to submit current copies of required documents. Essential documents include the state medical license, DEA certificate, and curriculum vitae, among others. Not providing these documents can result in the application being deemed incomplete.
Inaccurate or incomplete identifying information is also a common issue. Applicants should ensure that all fields, such as name, address, and social security number, are filled out correctly. Missing or incorrect information can cause significant delays.
Many applicants forget to indicate whether they have been known by any other names. This information is vital for verifying the applicant’s credentials and history. Failing to include this can complicate background checks.
Another frequent oversight is neglecting to specify the practice information accurately. This includes providing the correct primary office address and contact details. Incorrect information can lead to difficulties in communication and coordination.
Some applicants may not fully understand the questions regarding affiliations with other networks. It is important to provide accurate details about any networks in which they participate or have been denied admission. This information is crucial for the managed care entity's review process.
Additionally, applicants often forget to list any clinical services they perform that are not typically associated with their specialty. This section allows for a more comprehensive understanding of the applicant's capabilities and should not be overlooked.
Finally, one of the most significant mistakes is not reviewing the entire application before submission. Errors can easily go unnoticed, but a thorough review can help catch mistakes that could delay the application process.
CONFIDENTIAL/PROPRIETARY
Please check one:
Mississippi Participating Physician
Original Application
Application
Reappointment
This application is submitted to:_______________________________, herein, this Managed Care Entity 1.
SECTION A.
Practice, Educational, Licensure and Work History Information
I. INSTRUCTIONS
This form should be typed or legibly printed in black ink. If more space is needed than provided on original, attach additional sheets and reference the questions being answered. Please do not use abbreviations when completing the application. If an item in the application does not apply to you, write N/A in the box provided. Current copies of the following documents must be submitted with this application.
z State Medical License(s)
z Face Sheet of Professional Liability Policy or Certification
z DEA Certificate
z Curriculum Vitae
z Board Certification (if applicable)
z ECFMG (if applicable)
II. IDENTIFYING INFORMATION
Last Name:
First:
Middle:
Is there any other name under which you have been known (AKA/Maiden Name)? Name(s):
Home Mailing Address:
City:
State:
ZIP:
Home Telephone Number:
E-Mail Address:
Home Fax Number:
Pager Number:
Birthday Date:
Birth Place (City/State/Country):
Citizenship (If not a United States citizen, please include a copy of
Alien Registration Card).
Social Security #:
Gender 2 :
Male
Female
Race/Ethnicity 2
Specialty:
(voluntary):
Subspecialties:
Internal Medicine
III. PRACTICE INFORMATION
Practice Name (if applicable):
Department Name (if Hospital based):
Primary Office Street Address:
Primary Office Mailing Address if different from Street Address:
County:
Zip:
Telephone Number:
FAX Number:
Office Manager/Administrator:
Fax Number:
Name Affiliated with Tax ID Number:
Federal Tax ID Number:
1As used in the information Release/Acknowledgements Section of this application, the term “this Managed Care Entity” shall refer to
the entity to which the application is submitted as identified above.
2 This information will be used for consumer information purposes only.
Mississippi Participating Physician Application – 11/99
Page 1 of 12
Secondary Office Street Address:
Tertiary Office Street Address:
(
)
Handicap Access:
24 Hour Coverage:
Yes
No
Will you accept new patients?
Back office Telephone Number:
Please identify other networks in which you participate:
Please identify other networks from which you have been denied admission or de-selected:
Name of Network
Address
Reason for Denial or Deselection
Do you have ownership in any health or medical related organization, e.g., laboratory, home health care agency, radiology facility,
lithotrips, mobile testing, MRI, etc?
If Yes, please list:
Medical Group(s) / IPA(s) Affiliation:
Do you intend to serve as a primary care provider?
Please check all that apply:
Do you intend to serve as a specialist?
Solo Practice
Single Specialty
If Yes, please list specialty(s):
Group Practice
Multi Specialty
Do you employ any allied health professionals (e.g. nurse practitioners, physician assistants, psychologists, etc.)?
If so, please list:
Name:
Type of Provider:
License Number:
______________________________________ _______________________________________________________________________
______________________________________ __________________________________________________ _____________________
______________________________________ ___________________________________________________ _____________________
Do you personally employ any physicians? (Do Not include physicians that are employed by the medical group)
Mississippi Medical License Number:
_________________________________________________________________
_____________________________________________
____________________________________________
Page 2 of 12
Please list any clinical services you perform that are not typically associated with your specialty:
Please list any clinical services you do not perform that are typically associated with your specialty:
Is your practice limited to certain ages?
If Yes, specify limitations:
NO
Do you participate in EDI (electronic date interchange)?
Do you use a practice management system/software: Yes
If so, which Network?
If so, which one?
What type of anesthesia do you provide in your group/office?
Local
Regional
Conscious Sedation
General
None
Other (please specify):
___________________
Has your office received any of the following accreditation’s, certifications, or licensures?
American Association for Accreditation of Ambulatory Surgery Facilities (AAASF)
Medicare Certification
Mississippi Department of Health Licensure
Other:
IV. BILLING INFORMATION
Billing Company:
Street Address:
Contact:
V. OFFICE HOURS – Please indicate the hours your office is open:
Monday
Tuesday
Wednesday
Thursday
Friday
24 HOUR
COVERAGE
Saturday
24HOUR COVERAGE
Sunday
Holidays
VI. COVERAGE OF PRACTICE (List your answering service and covering physicians by name. Attach additional sheets if necessary. Reference this section number and title)
Answering Service Company:
Telephone Number: ( )
Fax Number: ( )
Mailing Address:
Covering Physician’s Name:
If you do not have hospital privileges, please provide written plan for continuity of care:
Page 3 of 12
VII. FOREIGN LANGUAGES SPOKEN
Fluently by Physician:
Fluently by Staff:
VIII. LABORATORY SERVICES
If you provide direct laboratory services, please indicate the TIN utilized and provide Clinical Laboratory Information Act (CLIA) information. Attach a copy of your CLIA certificate or waiver if you have one.
Tax ID #:
Billing Name:
Type of Service Provided:
Do you have a CLIA Certificate?
Do you have a CLIA waiver?
Certificate Number:
Certificate Expiration Date:
IX. MEDICAL/PROFESSIONAL EDUCATION
(Attach additional sheets if necessary. Reference this
section number and title.)
Medical School:
Degree Received:
Date of Graduation (mm/yy)
State & Country:
Medical/Professional School:
State & Country
X.
INTERNSHIP/PGYI (Attach additional sheets if necessary, Reference this section number and title.)
Institution:
Program Director:
Type of Internship:
From: (mm/yy)
To: (mm/yy)
XI.
RESIDENCES/FELLOWSHIPS (Attach additional sheets if necessary. Reference this section
number and title.)
Include residencies, fellowships, preceptorships, teaching appointments (indicate whether clinical or academic). And postgraduate education in chronological order, giving name, address, city, state, country, zip code and dates. Include all programs you attended, whether or not completed.
Type of Training (e.g. residency, etc)
Did you successfully complete the program?
No (If “No”, please explain on separate sheet.)
Page 4 of 12
(If “No”, please explain on separate sheet.)
XII. BOARD CERTIFICATION (Attach copies of documents.)
Include certifications by board(s) which are duly organized and recognized by: z a member board of the American Board of Medical Specialties
z a member board of the American Osteopathic Association
z a board or association with an Accreditation Council for Graduate Medical Education of American Osteopathic Association approved post graduate training that provides complete training in that specialty or subspecialty.
Name of Issuing Board:
Certification Number:
Date Certified/ Rectified:
Expiration Date (if any):
Have you applied for board certification other than those indicated above?
Yes No
If so, list board(s) and date(s):
If not certified, describe your intent for certification, if any, and date of admissibility for certification on separate sheet.
Have you taken or failed a board exam?
If Yes, Provide details.
XIII. OTHER CERTIFICATIONS (e.g. Fluoroscopy, Radiography, etc.) (Attach additional sheets if necessary.
Reference this section number and title.)
Type:
Number:
Expiration Date:
XIV. MEDICAL LICENSURE/REGISTRATIONS (Attach copies of documents)
Mississippi State Medical License Number:
Issue Date:
Active:
Drug Enforcement Administration (DEA) Registration Number:
Unlimited?
No If “No”, please explain on separate sheet
Controlled Dangerous Substances Certificate (CDS) (if applicable):
Page 5 of 12
ECFMG Number (applicable to foreign medical graduates):
Visa Number:
Date Issued:
Valid Through:
Medicare UPIN/National Physician Identifier (NPI):
Mississippi Medicare Number:
Mississippi Medicaid Number:
XV. ALL OTHER STATE MEDICAL LICENSES – List all Medical licenses now or Previously Held. (Attach additional sheets if necessary. Reference this section number and title.)
State
XVI. PROFESSIONAL ORGANIZATIONS
Please list county, state or national medical societies, or other professional organizations or societies of which you are a member or applicant.
ORGANIZATION NAME
Applicant
Member
Are you an Officer or Director of any of the professional organizations listed above?
XVII. PROFESSIONAL LIABILITY (Attach copy of professional liability policy or certification face sheet.)
Current Insurance Carrier:
Policy Number:
Original effective date:
( )
Per Claim Amount: $
Aggregate Amount: $
Please explain any surcharges to your professional liability coverage on a separate sheet. Reference this section number and title.
If you have had professional liability carriers in the last five years other than the one listed above, please list them below.
Name of Carrier:
Policy # :
State and Country::
State and Country:
Page 6 of 12
XVII. CURRENT HOSPITAL AND OTHER INSTITUTIONAL AFFILIATIONS
Please list in (A) in reverse chronological order, with the most current affiliation(s) first, all institutions with which you are currently affiliated. List previous affiliations during the past ten years in (B). Include hospitals, surgery centers, institutions, corporations, military assignments, or government agencies.
A. CURRENT AFFILIATIONS (Attach additional sheets if necessary. Reference this section number and title.)
Name and Mailing Address of Primary Admitting Hospital:
Department/Status (Active, provisional, courtesy, etc.):
Appointment Date:
Name and Mailing Address of Other Hospital/Institution:
Department/Status (Active, provisional, courtesy, etc)
If you do not have hospital privileges, please explain.
B. PREVIOUS AFFILIATIONS (Limit to last ten years. Attach additional sheets if necessary. Reference this section number and title.)
Reason for Leaving:
Name and Mailing Address of other Hospital/institution:
Page 7 of 12
XIX. PEER REFERENCES
List three professional references, preferably from your specialty area. Do not list relatives, current partners or associates in practice. If possible, include at least one member from the Medical Staff of each facility at which you have privileges. Do not include program directors previously listed under post graduate training and education in Section X.
NOTE: References must be from individuals who are directly familiar with your work, either via direct clinical observation or through a close working relationship.
Name of Reference:
XX. WORK HISTORY (Attach additional sheets if necessary. Reference this section number and title.)
Chronologically list all work history for at least the past five years (use extra sheets if necessary). This information must be complete. A curriculum vitae is sufficient provided it is current and contains all information requested below. Please explain any gaps in professional work history on a separate page.
Current Practice:
Contact Name:
Name of Practice/Employer:
Page 8 of 12
Section B.
Professional Liability Action Explanation
Please complete this section for each pending, settled, or otherwise concluded professional liability lawsuit or arbitration filed and served against you, in which you were named a party in the past five (5) years, whether the lawsuit or arbitration is pending, settled or otherwise concluded, and whether or not any payment was made on your behalf by any insurer, company, hospital, or other entity. All questions must be answered completely in order to avoid delay in expediting your application. If there is more than one professional liability lawsuit or arbitration action, please photocopy this Section B prior to completing, and complete a separate form for each lawsuit.
I. CASE INFORMATION
City, County and State where lawsuit filed:
Court case number, if known:
Date of alleged incident serving as basis for the lawsuit/arbitration:
Date Suit Filed:
Sex of patient:
Age of patient:
Location of Incident:
Hospital
My office
Other doctor’s office
Surgery Center
Other, (please specify)
__________________________________________________________________________________
Your relationship to Patient (Attending Physician, Surgeon, Assistant, Consulting, etc.):
Allegation:
Is/was there any insurance company or other liability protection company or organization providing coverage/defense of the lawsuit or
arbitration action?
If Yes, please provide company name, contact person, phone number, location and claim identification number of insurance company or other liability protection company or organization.
_________________________________________________________________________________________________________________
If you would like us to contact your attorney regarding any of the above, please provide attorney(s) name(s) and phone number(s). Please fax this document to your attorney to serve as your authorization:
Name: ____________________________________________________ Phone Number: _________________________________
Name: ____________________________________________________ Phone Number: __________________________________
II. WHAT IS THE STATUS OF THE LAWSUIT/ARBITRATION DESCRIBED ABOVE? (CIRCLE ONE)
Lawsuit/arbitration still ongoing, unresolved.
Judgement rendered and payment was made on my behalf.
Amount paid on my behalf:
_______________________
Judgement rendered and I was found not liable.
Lawsuit/arbitration settled and payment made on my behalf.
________________________
Lawsuit/arbitration settled, no judgement rendered, no payment made on my behalf.
Summarize the circumstances giving rise to the action. If the action involves patient care, provide a narrative, with adequate clinical detail, including your description of your care and treatment of the patient. If more space is needed, attach additional sheet(s). Include: (1) condition and diagnosis at time of incident. (2) dates and description of treatment rendered, and (3) condition of patient subsequent to treatment. Please print.
Page 9 of 12
SUMMARY
SECTION C.
Certification
I certify that the information in Section A and B of this application and any attached documents (including my curriculum-vitae if attached) is true, current, correct and complete to the best of my knowledge and belief and is furnished in good faith. I understand that intentionally withholding or omitting material information or intentionally submitting material false or misleading information may result in denial of my application or termination of my privileges, employment or physician participation agreement. I agree that the Managed Care Entity to which this application is submitted, its representatives, and any individuals or entities providing information to this Managed Care Entity in good faith shall not be liable, to the fullest extent provided by law, for any act or occasion related to the evaluation or verification contained in this Mississippi Participating Physician Application. In order for participating Managed Care Entities or Healthcare Organizations to evaluate my application for participation in and/or my continued participation in those organizations, I hereby give permission to release to this Managed Care Entity information about my medical malpractice insurance coverage and malpractice claims history. This authorization is expressly contingent upon my understanding that the information provided will be maintained in a confidential manner and will be shared only in the context of legitimate credentialing and peer review activities. This authorization is valid unless and until it is revoked by me in writing. I authorize the attorneys listed in Section B, Page 9, to discuss any information regarding the subject case with this Managed Care Entity.
Print Name Here: ___________________________________________________________________________
Physician Signature: ____________________________________________________________ Date: __________________________
(Stamped Signature Is not Acceptable)
Page 10 of 12
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