Facility Attestation Facilities providing primary care and obstetrics and gynecology services must attest to the following areas of competencies by signing below. Please describe your processes for each category. Neighborhood retains the right to conduct a quality on onsite assessment prior to the facility joining the network (initial credentialing) or in response to a complaint received from a member pertaining to environment of care. Ability to handle medical emergencies in the FacilityFacility has the ability to manage unexpected medical emergencies and maintains in good working order equipment needed to manage emergencies, including:Severe Allergic Reaction* Yes No Severe Allergic Reaction - Please describe your process or indicate whether a policy is attached*Cardio-pulmonary Arrest* Yes No Cardio-pulmonary Arrest - Please describe your process or indicate whether a policy is attached*Staff is trained and facility ensures that training is current* Yes No Staff is trained and facility ensures that training is current - Please describe your process or indicate whether a policy is attached*Facility has a process for transferring patients to an emergency room* Yes No Facility has a process for transferring patients to an emergency room - Please describe your process or indicate whether a policy is attached*Ability to handle medical emergencies in the Facility - Please upload any applicable documents Drop files here or Select files Accepted file types: pdf, Max. file size: 5 MB. Physical accessibility and maintenanceOffice is handicapped accessible (including restrooms)* Yes No Office is handicapped accessible (including restrooms) - Please describe your process or indicate whether a policy is attached*If injectable medication is administered – there is a process for regular disposal of needle/syringes* Yes No If injectable medication is administered – there is a process for regular disposal of needle/syringes - Please describe your process or indicate whether a policy is attached*Containers are out of reach of children* Yes No Containers are out of reach of children - Please describe your process or indicate whether a policy is attached*If narcotics are administered, narcotics are stored in double locked storage* Yes No If narcotics are administered, narcotics are stored in double locked storage - Please describe your process or indicate whether a policy is attached*Process for checking narcotics validation is in place* Yes No Process for checking narcotics validation is in place - Please describe your process or indicate whether a policy is attached*There is a process in place for discarding narcotics* Yes No There is a process in place for discarding narcotics - Please describe your process or indicate whether a policy is attached*Physical accessibility and maintenance - Please upload any applicable documents Drop files here or Select files Accepted file types: pdf, Max. file size: 5 MB. Medical Records Keeping and ConfidentialityFacility has policies and procedures re adequacy of medical record keeping (paper/electronic/both) which includes:The patient record is secured and accessible to authorized personnel only* Yes No The patient record is secured and accessible to authorized personnel only - Please describe your process or indicate whether a policy is attached*Record is legible* Yes No Record is legible - Please describe your process or indicate whether a policy is attached*There is a written medical record policy that addresses security and confidentiality of the record* Yes No There is a written medical record policy that addresses security and confidentiality of the record - Please describe your process or indicate whether a policy is attached*There is a process for retention of active and inactive files* Yes No There is a process for retention of active and inactive files - Please describe your process or indicate whether a policy is attached*There is a process regarding release of information requests* Yes No There is a process regarding release of information requests - Please describe your process or indicate whether a policy is attached*Records are available to covering practitioners* Yes No Records are available to covering practitioners - Please describe your process or indicate whether a policy is attached*Consent or refusal of treatment is documented in the record* Yes No Consent or refusal of treatment is documented in the record - Please describe your process or indicate whether a policy is attached*All employees sign a confidentiality agreement and receive instruction regarding HIPAA* Yes No All employees sign a confidentiality agreement and receive instruction regarding HIPAA - Please describe your process or indicate whether a policy is attached*Medical Records Keeping and Confidentiality - Please upload any applicable documents Drop files here or Select files Accepted file types: pdf, Max. file size: 5 MB. Internal Policies and ProceduresFacility has documented processes for handling:Patient grievances* Yes No Patient grievances - Please describe your process or indicate whether a policy is attached*Employee training* Yes No Employee training - Please describe your process or indicate whether a policy is attached*Hospitalization for patients needing inpatient care* Yes No Hospitalization for patients needing inpatient care - Please describe your process or indicate whether a policy is attached*Practitioner coverage is available 24 hours per day 7 days per week* Yes No Practitioner coverage is available 24 hours per day 7 days per week - Please describe your process or indicate whether a policy is attached*Internal Policies and Procedures - Please upload any applicable documents Drop files here or Select files Accepted file types: pdf, Max. file size: 5 MB. By signing below, I attest that this Facility has the capability to handle the key areas specified aboveName* Signature*Title* Date MM slash DD slash YYYY Practice InformationPractice Name* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Fax*Site Liaison/Contact Person* Service* Primary Care Obstetrics & Gynecology Both Medical Director* Please upload any applicable documents Drop files here or Select files Accepted file types: pdf, Max. file size: 5 MB. Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network. CAPTCHA PhoneThis field is for validation purposes and should be left unchanged.