Individual Practice Package

Memo

To:

New CredAxis Individual Provider

From:

Elizabeth Duffin (Collins), Credentialing & Project Manager, eduffin@credaxis.com Matt Romeo, Project Manager, mromeo@credaxis.com

Re:

New Individual Provider Information

Dear Provider,

Welcome to the CredAxis Family!

Please complete the paperwork attached to get your credentialing process started . Please be sure to sign all paperwork in BLUE INK (DO NOT DATE ANY DOCUMENTS) at area denoted by a *. This is indicative of the required originals when we forward paperwork for processing . Please do not skip any portions of the attached provider group information forms.

Kindly return copies of your group New Practice Checklist documents (We do not need the originals) with your signed paperwork.Any missing or incomplete information will delay the credentialing process.

Please contact us if you have any questions.

Regards,

Elizabeth Duffin (Collins)
Credentialing Manager

Matt Romeo
Project Manager

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Attention: Credentialing Department
1214 Mariner Blvd
Spring Hill, FL 34609-5657

Credentialing Documentation Checklist

Demographics registration information and Documentation needed

Licensure & Certificates (Current clear copies needed)

Education Documentation (Current clear copies needed)

Please return all documents to the below contact as soon as possible . Please note that failure to send credentialing documentation needed will result in the delay of your participation with our group.

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Attention: Credentialing Department
1214 Mariner Blvd
Spring Hill, FL 34609-5657 Phone:352-794-9994

Physician Demographic Information Form

Provider Type

NPI Number

Gender

Provider Name(FN, MI, LN)

Marital Status

Have you ever used another Name?

Home Address

State

County

City

Zip-Code

Length of time

Home Phone

Home Fax

Cell Phone

Primary Email Address

Secondary Email Address

S.S.N

Driver's License Number

Driver's License State

DOB

**Place Of Birth Country

Place Of Birth State

Place Of Birth City

Are you a U.S Citizen

Fluent Languages other than English

Do you communicate in American Sign Language

Identification & Licenses

Primary License {{$index+1}} Type?

Medical License #

Expiration Date

DEA Licensing

DEA #

Issue Date

Expiration Date

Schedules

Controlled Drug Substances (CDS Licensing)

CDS #

Issue State

Issue Date

Expiration Date

Unique Provider Identification Number

UPIN #

Education History

School Name

Degree Awarded

Start Date

Graduate Date

School Name

Degree Awarded

Start Date

Graduate Date

ECFMG #

Issue Date

Hospital Name

Specialty

Degree Awarded

Start Date

End Date

Hospital Name

Specialty

Director Name

Start Date

End Date

Hospital Name

Specialty

Director Name

Start Date

End Date

Provider Specialty

Primary Secondary Tertiary Practicing Specialty

Taxonomy Code

Board Certified


Practice Location Information

Primary Secondary Tertiary Practice Location :

Legal Group Name

Group TIN

Start Date

Address

Suite #

City

State

Zip-Code

County

Phone

Fax

Office Manager:

Office Manager First Name

Last Name

Phone

Fax

Email

What Days of the week & hours will you be at this location?

Day Start Time End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Open Practice Questions

Question Yes No Comments
Accept New Patients into Practice?
Accept Medicare?
Accept Medicaid?
Accept New Patients with Physician Referral?
Accepting Existing patients with Change of payer?
Are you Panels Close for any payers?
Gender Limitations?

Treating Age Ranges

Billing Contact / Address

Billing Contact First Name

Last Name

Phone

Fax

Email

Address

Suite #

City

State

Zip-Code

County

Phone

Fax

Payment / Remittance Address

Make Check Payable to

Billing Contact First Name

Last Name

Phone

Fax

Email

Address

Suite #

City

State

Zip-Code

County

Phone

Fax

Correspondence Address:

Address

Suite #

City

State

Zip-Code

County

Phone

Fax


Adverse Action History: Documentation needed for all YES answers

Have you ever had any Adverse Legal Actions / Convictions?

Has you Medical License or DEA ever been involuntarily or voluntarily denied, suspended or revoked or ever had a disciplinary action or conditions applied?

Have you had any Malpractice Claims in the last 10 years?

Have you ever been excluded from Medicare?

Have you ever been excluded from Medicaid?

Have any of your board certifications or eligibility ever been revoked or suspended?

Have you hospital privileges ever been revoked, suspended, limited or denied?

CAQH & NPI Registry

In order to credential and attach a provider to our group contracts we must have accurate working logins.

Please keep in mind that the User Names and Passwords for both of these sources are case sensitive. Please be sure to give the correct logins to avoid any credentialing delays.

CAQH

If you do not know your CAQH User Name / Password you will need to call the Help Desk and Request this be reset. When you call, please be sure to have your email address for notifications changed to credentialing@credaxis.com as we will assist with all maintenance.CAQH Help Desk Telephone: 888-599-1771

User Name

Password

NPI Registry

The NPI Registry is used for Medicare Enrollment and is EXTREMELY VITAL to your credentialing. If you do not know your user name or password we can assist with resetting this directly on the website and will email you the User Name / Password upon reset.

User Name

Password

I authorize, PrimeCare Credentialing LLC and its affiliated companies to reset , modify and notify me of any changes to my CAQH & NPI Registry Profiles as required by all payers and government agencies . I understand that if at any time I change my User Name / Password I will need to inform the Credentialing Department via email (credentialing@credaxis.com) or telephone:352-796-9994 within 24-48 hours and failing to notify the Credentialing Department of any changes to my CAQH & NPI Registry User Names or Passwords could result in a delay in my credentialing.

Provider Name

*Signature

Date

Hospital Privileges

Do you current have any active Hospital Privileges?

Peer References (all 3 are MANDATORY)

REFERENCE 1

Provider Type

Other

Provider First Name

M.I

Provider Last Name

Provider Address

City

State

Zip-Code

Telephone#

Fax#

Email Address

Provider Specialty

Relationship

Board Certified?


REFERENCE 2

Provider Type

Other

Provider First Name

M.I

Provider Last Name

Provider Address

City

State

Zip-Code

Telephone#

Fax#

Email Address

Provider Specialty

Relationship

Board Certified?


REFERENCE 3

Provider Type

Other

Provider First Name

M.I

Provider Last Name

Provider Address

City

State

Zip-Code

Telephone#

Fax#

Email Address

Provider Specialty

Relationship

Board Certified?

Insurance Participating History


Areas of Clinical Expertise (PSYCH QUESTIONNARE)

Please check all areas you have clinical training experience AND are currently willing to treat in your practice.

Areas of Clinical Expertise Cont’d

Population(s) Treated (check all that apply)

Physician Specialties Physician Specialties Non-Physician Specialties

Physician Specialties Physician Specialties Non-Physician Specialties