Organizational Provider Credentialing Application

Instructions:
Complete the application and sign page 3. Provide additional detail as necessary on page 4.
NOTE: Signatures MUST be original or electronic; stamps cannot be accepted.
Please return the completed and signed application along with copies of the following updated documents:

State license(s)
Certificate(s) for all behavioral health services provided; include all certificates for all facility locations(when applicable)
Facility administrator license (when applicable)
Director of nursing license (when applicable)
Professional Liability Insurance Face Sheet (minimum limits of $5M / $5M for inpatient mental health/or inpatient rehabilitation SUD and $1M / $3M for all other levels of mental health/SUD)
Certified Laboratory Improvement Amendments (CLIA) certification (when applicable)
Most recent survey by CMS, Department of Health Facility Regulation (DOH), Department of Behavioral Healthcare, Developmental Disabilities & Hospital (BHDDH), or other agency, including corrective action plan if deficiencies were cited and evidence that all deficiencies are remedied (when applicable)
Accreditation certificate (when applicable; Neighborhood may conduct a site visit at facilities not accredited by an accrediting agency accepted by Neighborhood)
Enhanced Services Attestation (Adult Day Care/Assisted Living providers only)

If you have any questions regarding this application, please call Neighborhood’s Credentialing Department at 459-6000.

Facility Type

Check all that apply

Facility Demographics

Legal Business Name*

Doing Business As (DBA) Name

If applicable

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Email*

Enter Email Confirm Email

Credentialing Contact

Name*

First Last

Credentialing Mailing Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Email*

Enter Email Confirm Email

Please provide the following information, when applicable:

Facility Administrator: Name and State License #

Director of Nursing: Name and State License #

Medical Director: Name and State License #

Clinical Laboratory Director: Name and State License #

For initial credentialing, provide information pertaining to the past 10 years. For Re-credentialing, provide information pertaining to the past 3 years. Please use page 4 to provide additional information for responses with an asterisk(*)

Facility /Administrator

1. Has this facility had an initial on-site survey conducted by the following?

CMS
Department of Health Facility Regulation (DOH)
Department of Behavioral Healthcare, Developmental Disabilities, and Hospital (BHDDH)
Other agency ______________________

Please explain*

(Other agency)

a. Date of most recent full onsite survey by CMS*

b. Were any deficiencies identified during the on-site survey by CMS?*

b. Were any deficiencies identified during the on-site survey by CMS? *

Yes
No

(If yes, provide evidence of acceptance of the Corrective Action Plan)

CAP (Corrective Action Plan) File*

Accepted file types: pdf, docx, Max. file size: 5 MB.

a. Date of most recent full onsite survey by DOH*

b. Were any deficiencies identified during the on-site survey by DOH?*

b. Were any deficiencies identified during the on-site survey by DOH? *

Yes
No

(If yes, provide evidence of acceptance of the Corrective Action Plan)

CAP (Corrective Action Plan) File*

Accepted file types: pdf, docx, Max. file size: 5 MB.

a. Date of most recent on-site survey by the Department of Behavioral Healthcare, Developmental Disabilities, and Hospital (BHDDH)?*

b. Were any deficiencies identified during the on-site survey by BHDDH?*

b. Were any deficiencies identified during the on-site survey by BHDDH? *

Yes
No

(If yes, provide evidence of acceptance of the Corrective Action Plan)

CAP (Corrective Action Plan) File*

Accepted file types: pdf, docx, Max. file size: 5 MB.

2. Has any formal complaint been filed with CMS or any state agency?*

2. Has any formal complaint been filed with CMS or any state agency? *

Yes
No

Detailed Summary

3. Is the facility currently on any Corrective Action Plan with any Board of Facility Regulation, CMS or any other organization?*

3. Is the facility currently on any Corrective Action Plan with any Board of Facility Regulation, CMS or any other organization? *

Yes
No

Detailed Summary

4. Have any formal or written claims, or any professional or general liability lawsuits been filed, settled and/or adjudicated or is currently pending against the facility?*

4. Have any formal or written claims, or any professional or general liability lawsuits been filed, settled and/or adjudicated or is currently pending against the facility? *

Yes
No

Detailed Summary

5. Has the liability insurance coverage been cancelled, denied or modified (e.g. reduced limits, restricted coverage), denied renewal or surcharge applied?*

5. Has the liability insurance coverage been cancelled, denied or modified (e.g. reduced limits, restricted coverage), denied renewal or surcharge applied? *

Yes
No

Detailed Summary

6. Has the facility ever been required or agreed to pay civil monetary penalties under Medicare or Medicaid or otherwise sanctioned by CMS?*

6. Has the facility ever been required or agreed to pay civil monetary penalties under Medicare or Medicaid or otherwise sanctioned by CMS? *

Yes
No

Detailed Summary

7. Has any Federal or State agency ever taken any action which limited this facility?*

7. Has any Federal or State agency ever taken any action which limited this facility? *

Yes
No

Detailed Summary

8. Has the facility ever voluntarily surrendered or had your license refused, restricted, suspended or revoked in any state?*

8. Has the facility ever voluntarily surrendered or had your license refused, restricted, suspended or revoked in any state? *

Yes
No

Detailed Summary

9. Is criminal background check performed for all personnel employed by the facility?*

9. Is criminal background check performed for all personnel employed by the facility? *

Yes
No

Detailed Summary

10. 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?*

10. 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? *

Yes
No

Detailed Summary

Refer to Question #4 (Professional Liability Experience/History):

Carrier at Time of Incident*

Date of Alleged Incident*

Date of Lawsuit Filed*

Name of Court*

Case Number*

Date of Settlement

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*

Consent*

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*

Title*

Signature*

Date*

Facility License*

Accepted file types: pdf, docx, Max. file size: 2 MB.

Current Professional Liability Insurance Face Sheet*

Accepted file types: pdf, docx, Max. file size: 2 MB.

Certified Laboratory Improvement Amendments (CLIA) certification

Accepted file types: pdf, docx, 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, docx, Max. file size: 2 MB.

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