ࡱ> ')$%&q` :-bjbjqPqP 26::QC.......BLLL8LM$BqnOX(XXX*Z2\\,]?pApApApApApAp$shnuep.)a&Z&Z)a)aep..XX4Rqggg)a.X.X?pg)a?pgg:Wh,..hXO 09c L/bh h|hq0qh vblvhv.h, ^^rg2_\_ ^ ^ ^epep5gX ^ ^ ^q)a)a)a)aBBB)2BBB2BBB...... New Jersey Physician Recredentialing Application (Please type or print) All sections must be completed fully or clearly marked as not applicable. No area should be left blank. SECTION 1Personal InformationPhysician Name (Last) (First) (MI) (Jr., Sr., etc.)  FORMTEXT      UPIN  FORMTEXT      Social Security Number  FORMTEXT      Corporate Name (if different from name above)  FORMTEXT      Professional Degree(s)  FORMTEXT       Practice Location Information - Primary OfficePrimary Office Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Telephone No.  FORMTEXT      Fax No.  FORMTEXT      Tax ID Number and Associated Individual Group Number and Name for This Location  FORMTEXT      Non-English Languages Spoken (Health Care Provider)  FORMTEXT      Non-English Languages Spoken (Office Staff)  FORMTEXT      Handicap Access  FORMCHECKBOX  Yes  FORMCHECKBOX  No Continuing EducationPlease list all continuing education for the past two years.Course NameLocationDate TakenNumber of CME/CEUs FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Professional/Medical Specialty InformationPrimary Specialty  FORMTEXT      Board Certified?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Professional Certificates, Licenses, Identification NumbersAre you a Member of your State Medical Society?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoPrimary State License Number  FORMTEXT      State  FORMTEXT      Expiration Date  FORMTEXT      List any additional licenses (current or expired) within the last 15 years:License NumberStateExpiration Date FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Federal DEA Number  FORMTEXT      Expiration Date  FORMTEXT      CDS Number  FORMTEXT      Expiration Date  FORMTEXT       NEW JERSEY PHYSICIAN RECREDENTIALING APPLICATION (Continued) Hospital AffiliationsPrimary Admitting Facility  FORMTEXT      From:  FORMTEXT      To:  FORMTEXT      Type of Appointment (Active, Courtesy, etc.)  FORMTEXT      Specialty  FORMTEXT      Additional Facilities:NameSpecialtyFrom/ToRestrictions FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Professional Liability Insurance CoverageName of Current Malpractice Insurance Carrier  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Policy Number  FORMTEXT      Period of Coverage  FORMTEXT      Amount of Coverage per Occurrence $ FORMTEXT      Amount of Coverage Aggregate $ FORMTEXT       Additional Office InformationAddress  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Telephone No.  FORMTEXT      Fax No.  FORMTEXT      E-mail Address  FORMTEXT      Does this office have capability for electronic billing?  FORMCHECKBOX  Yes  FORMCHECKBOX  No NEW JERSEY PHYSICIAN RECREDENTIALING APPLICATION (Continued) SECTION 2 - DISCLOSURE QUESTIONSPlease answer each question. If you respond Yes to any of the questions listed below, please provide an explanation on a separate sheet of paper. If question does not apply, please write in N/A. Licensure1. Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation or have you ever been subject to a consent order, probation or any conditions or limitations by any state licensing board?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 2. Has your federal or state narcotics license ever been suspended, limited, revoked, voluntarily suspended or not renewed, or has probation ever been invoked?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3. Have you ever received a reprimand or been fined by any state licensing board?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoHospital Privileges and Other Affiliations4. Have your clinical privileges at any hospital or healthcare institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 5. Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 6. Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs or PHOs)?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoEducation, Training and Board Certification7. Have you ever been placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, fellowship, preceptorship or other clinical education program?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 8. If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 9. Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10. Have any of your board certifications or eligibility ever been revoked?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 11. Have you ever chosen not to re-certify or voluntarily suspended your board certification(s) while under investigation?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoDEA or CDS Certification/Authorization12. Have your Federal and/or State Controlled Dangerous Substances (CDS) certificate(s) or authorization(s) ever been denied, suspended, revoked, restricted, denied renewal, or voluntarily relinquished?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoMedicare, Medicaid and Other Governmental Program Participation13. Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified, or otherwise restricted in regard to participation in the Medicare or Medicaid program, or any other private, federal or state health program?  FORMCHECKBOX  Yes  FORMCHECKBOX  No NEW JERSEY PHYSICIAN RECREDENTIALING APPLICATION (Continued) Other Sanctions or Investigations14. Are you currently or have you ever been the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 15. To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 16. Have you ever received sanctions from or been the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 17. Has a patient, employee, or co-worker ever accused you of sexual harassment or other illegal misconduct that resulted in an investigation, sanction or other formal action?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 18. During your military career, if applicable, have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or agency, voluntarily terminated or resigned while under investigation by a hospital/healthcare facility of any military agency?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoProfessional Liability Insurance Information19. Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 20. Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional liability insurance carrier, based on your individual liability history?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoMalpractice Claims History21. Have you ever had any malpractice actions (pending, settled, dropped, dismissed, arbitrated, mediated or litigated)? If yes, please provide information for each case (list each action separately).  FORMCHECKBOX  Yes  FORMCHECKBOX  No Date of occurrence Claim/case status Date claim was filed Professional liability insurance carrier involved (include name, address, phone number and policy number) Amount of award or settlement and amount paid: Method of Resolution: ( Dismissed ( Judgment for plaintiff(s) ( Mediation/Arbitration ( Settled (with prejudice) ( Judgment for defendant(s) ( Settled (without prejudice) Description of allegations Indicate whether you were primary defendant or co-defendant Number of other co-defendants Indicate your involvement in the case (attending, consulting, etc.) Description of alleged injury to the patientCriminal/Civil History (Note: A criminal record will not necessarily be a bar to acceptance. Decisions will be based upon all relevant circumstances, including the nature of the crime.)22. Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony in the last ten years or been found liable or responsible for or named as a defendant in any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 23. Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony in the last ten years or been found liable or responsible for or been named as a defendant in any civil offense that alleged fraud, an act of violence, child abuse or a sexual offense or sexual misconduct?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 24. Have you ever been indicted in any civil or criminal suit?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 25. Have you ever been court-martialed for actions related to your duties as a medical professional?  FORMCHECKBOX  Yes  FORMCHECKBOX  No NEW JERSEY PHYSICIAN RECREDENTIALING APPLICATION (Continued) Ability to Perform Job26. Are you able to perform the essential functions of a practitioner in your area of practice with or without reasonable accommodation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 27. Are you currently engaged in the illegal use of drugs? (Currently" means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on ones ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of an application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. Illegal use of drugs refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. section 812.22. It does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law. The term does include, however, the unlawful use of prescription controlled substances.)  FORMCHECKBOX  Yes  FORMCHECKBOX  No 28. Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 29. Do you have any reason to believe that you would pose a risk to the safety or well being of your patients?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 30. Do you have Professional Liability (Malpractice) Insurance coverage in force? (If No, please explain below.)  FORMCHECKBOX  Yes  FORMCHECKBOX  No NEW JERSEY PHYSICIAN RECREDENTIALING APPLICATION (Continued) SECTION 3 - AUTHORIZATION, ATTESTATION AND RELEASEI understand and agree that, as part of the recredentialing process for participation and/or clinical privileges at or with the above referenced managed care company (hereinafter referred to as the Entity) and any of the Entitys affiliates, I am required to provide sufficient and accurate information for proper evaluation of my current licensure, relevant training and experience, clinical competence, health status, moral character 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 will be held confidential to the extent permitted by law. I acknowledge that each Entity has its own criteria for acceptance, and I 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 do not guarantee that any Entity will grant me clinical privileges or contract with me as a provider of services. I understand that my application for participation is not an application for employment with the Entity and that acceptance of my application by the Entity will not result in my employment by the Entity. AuthorizationsInvestigation Concerning Application for Participation: I hereby authorize the following individuals, including the Entity, its representatives, employees, designated agent(s); the Entitys affiliates and their representatives, employees, or agent(s); the Entity's designated professional credentials verification organization (hereinafter collectively referred to as Agents), to investigate information, including oral and written statements, records, and documents, concerning my application for participation. I agree to allow the Entity and/or its Agent(s) to inspect all records and documents relating to such an investigation. Third-Party Sources to Release Information Concerning Application for Participation: I authorize 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 and 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, and the Health Care Integrity and Protection Data Bank, to release to the Entity and/or its Agent(s), information, including otherwise privileged or confidential information, concerning my professional qualifications, credentials, clinical competence, quality assurance and utilization data, character, mental and physical condition, alcohol or chemical dependency, diagnosis and treatment, ethics, or any other matter reasonably bearing on my qualifications for participation in, or with, the Entity. I authorize my current and past professional liability carrier(s) to release my history of claims that have been made and/or are currently pending against me. I specifically waive written notice from any entities and individuals who provide information based upon this Authorization, Attestation and Release. Release and Exchange of Disciplinary Information: I authorize any third party at which I currently have Participation or had Participation and/or the third partys agents to release Disciplinary Information, as defined below, to the Entity and/or its Agent(s). I authorize the Agent(s) to release Disciplinary Information about any disciplinary action taken against me to its participating Entities with which I have Participation, as may be otherwise required by law. 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I understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original. 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