Provider Application – Primary Care Provider

Instructions:

Please complete the below application and provide comments as appropriate.

All information is confidential.

Required fields are marked with an asterisk (*)

The information entered on this page can be saved to allow for completion at a later date. Incomplete requests will automatically delete from the system after 30 days of inactivity.
Date*
MM slash DD slash YYYY
Contact Name*
Contact Title*
Contact Phone Number*
Contact Email Address*
Enter Email Confirm Email
Section 1: Provider Information
Provider Name*

Include First Name, Middle Initial, and Last Name
Specialty*
NPI (Type I)*

10 Digit Number
Degree*
Section 2: Practice/Facility Information
Practice/Facility Name*
Title Role of Practice Owner

(i.e., Director, CEO, etc.)
Practice Owner's Full Name
NPI (Type II)*

10 Digit Number
Tax ID*
Address*
Street Address Address Line 2 City State ZIP
Office Phone Number*
Extension
Mailing Address (If different than above)
Street Address Address Line 2 City State ZIP
Website URL

Start with https://
Hours of Operation
Sunday - Open*

: Hours

Minutes

AM/PM
Sunday - Close*

: Hours

Minutes

AM/PM
Monday - Open*

: Hours

Minutes

AM/PM
Monday - Close*

: Hours

Minutes

AM/PM
Tuesday - Open*

: Hours

Minutes

AM/PM
Tuesday - Close*

: Hours

Minutes

AM/PM
Wednesday - Open*

: Hours

Minutes

AM/PM
Wednesday - Close*

: Hours

Minutes

AM/PM
Thursday - Open*

: Hours

Minutes

AM/PM
Thursday - Close*

: Hours

Minutes

AM/PM
Friday - Open*

: Hours

Minutes

AM/PM
Friday - Close*

: Hours

Minutes

AM/PM
Saturday - Open*

: Hours

Minutes

AM/PM
Saturday - Close*

: Hours

Minutes

AM/PM
Section 3: Other Provider Information
Has the provider ever been excluded from participating with Medicare/Medicaid*
Has the provider ever been excluded from participating with Medicare/Medicaid *
- Yes
- No
Per regulatory requirements any provider who is excluded from participation with Medicaid and/or Medicare is unable to join the network. We encourage you to apply in the future should circumstances change.
If you have any questions please address them in the below section.
Please Attach A Current W-9. W-9 Must have been completed within 6 months of today’s date.*
Accepted file types: pdf, Max. file size: 10 MB.
Primary Care Participation Questionnaire:
Primary Care Provider (PCP) means the individual Participating Practitioner selected by, or assigned to the member to provide and coordinate all of the member's health care needs and to initiate and monitor referrals for specialized services when required. PCPs shall be medical doctors or doctors of osteopathy in the following specialties: family and general practice, pediatrics, gynecology, internal medicine, geriatrics, and may include of mid-level practitioners.

Primary Care Providers also shall meet Neighborhood’s credentialing requirements as they relate to prescriptive privileges (DEA & CDS), mechanisms to admit and monitor inpatient care, and contain at least 3 years of training in a specialty defined above.

Please indicate whether or not each of the following statements applies to your practice.
1. Practice employs clinicians trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern not limited by problem origin, organ system, or diagnosis.*
1. Practice employs clinicians trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern not limited by problem origin, organ system, or diagnosis. *
- Yes
- No
Practice employs clinicians trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern not limited by problem origin, organ system, or diagnosis - Comments*
2. Practice provides diagnosis and treatment of acute and chronic conditions including but not limited to chronic lung disease, diabetes, and obesity.*
2. Practice provides diagnosis and treatment of acute and chronic conditions including but not limited to chronic lung disease, diabetes, and obesity. *
- Yes
- No
Practice provides diagnosis and treatment of acute and chronic conditions including but not limited to chronic lung disease, diabetes, and obesity - Comments*
3. Practice provides routine, yearly physical examinations in accordance to the American Academy of Pediatrics or other widely accepted adult guidelines (AAFP, CDC)*
3. Practice provides routine, yearly physical examinations in accordance to the American Academy of Pediatrics or other widely accepted adult guidelines (AAFP, CDC) *
- Yes
- No
Practice provides routine, yearly physical examinations in accordance to the American Academy of Pediatrics or other widely accepted adult guidelines (AAFP, CDC) - Comments*
4. Practice provides all adult vaccinations per CDC guidelines.*
4. Practice provides all adult vaccinations per CDC guidelines. *
- Yes
- No
Practice provides all adult vaccinations per CDC guidelines - Comments*
5. Practice provides all pediatric vaccinations per CDC guidelines.*
5. Practice provides all pediatric vaccinations per CDC guidelines. *
- Yes
- No
Practice provides all pediatric vaccinations per CDC guidelines - Comments*
6. Practice tracks, coordinates, and performs or orders recommended preventive care screenings including but not limited to: cancer (e.g. uterine, cervical, colorectal, breast), infectious disease (e.g. HIV, TB), hypertension, diabetes, hyperlipidemia, obesity, depression, and substance use disorders.*
6. Practice tracks, coordinates, and performs or orders recommended preventive care screenings including but not limited to: cancer (e.g. uterine, cervical, colorectal, breast), infectious disease (e.g. HIV, TB), hypertension, diabetes, hyperlipidemia, obesity, depression, and substance use disorders. *
- Yes
- No
Practice tracks, coordinates, and performs or orders recommended preventive care screenings including but not limited to: cancer (e.g. uterine, cervical, colorectal, breast), infectious disease (e.g. HIV, TB), hypertension, diabetes, hyperlipidemia, obesity, depression, and substance use disorders - Comments*
7. Practice provides preventive health counseling and anticipatory guidance including but not limited to: smoking avoidance/cessation, healthy eating habits, and reducing/avoiding alcohol use.*
7. Practice provides preventive health counseling and anticipatory guidance including but not limited to: smoking avoidance/cessation, healthy eating habits, and reducing/avoiding alcohol use. *
- Yes
- No
Practice provides preventive health counseling and anticipatory guidance including but not limited to: smoking avoidance/cessation, healthy eating habits, and reducing/avoiding alcohol use - Comments*
8. All practitioners are open to accepting new members.*
8. All practitioners are open to accepting new members. *
- Yes
- No
All practitioners are open to accepting new members - Comments*
9. Practice is open for 40 hours of appointment availability per week.*
9. Practice is open for 40 hours of appointment availability per week. *
- Yes
- No
If no, please describe the process to ensure access to care*
10. Do you have admitting privileges to any Hospitals? If yes, please indicate Hospital(s) to whom you refer patients to. If not please confirm whether you use a hospitalist?*
10. Do you have admitting privileges to any Hospitals? If yes, please indicate Hospital(s) to whom you refer patients to. If not please confirm whether you use a hospitalist? *
- Admitting Privileges
- Use a hospitalist
- Neither
Please indicate Hospital(s) to whom you refer patients below*
Please provide an explanation*
11. Practice provides for expanded access on evenings and/or weekends.*
11. Practice provides for expanded access on evenings and/or weekends. *
- Yes
- No
Please indicate the average number of week-night and weekend hours per week provided*
12. Practice has an Appointment System that promotes and provides same-day access.*
12. Practice has an Appointment System that promotes and provides same-day access. *
- Yes
- No
Practice has an Appointment System that promotes and provides same-day access -Comments*
13. Practice has Remote Systems of patient access to 24/7 care. On call physician call back within thirty (30) minutes from the time of the initial call.*
13. Practice has Remote Systems of patient access to 24/7 care. On call physician call back within thirty (30) minutes from the time of the initial call. *
- Yes
- No
If not, how are after-hours calls handled?*
14. How are patient calls handled during normal business hours? (I.e. are calls answered by an office representative or by an answering service?)*
15. Practice has an electronic medical record (EMR) with: Evidence- and guideline-based protocols embedded in the medical record; Capability to E-prescribe; and To provide electronic data to immunization registries.*
15. Practice has an electronic medical record (EMR) with: Evidence- and guideline-based protocols embedded in the medical record; Capability to E-prescribe; and To provide electronic data to immunization registries. *
- Yes
- No
Practice has an electronic medical record (EMR) with: Evidence- and guideline-based protocols embedded in the medical record; Capability to E-prescribe; and To provide electronic data to immunization registries - Comments*
16. Practice is accredited by the National Committee for Quality Assurance (NCQA)*
16. Practice is accredited by the National Committee for Quality Assurance (NCQA) *
- Yes
- No
Practice is accredited by the National Committee for Quality Assurance (NCQA) - Comments*
17. Practice and its practitioners are enrolled with Rhode Island Medicaid:*
17. Practice and its practitioners are enrolled with Rhode Island Medicaid: *
- Yes
- No
Per federal requirements, all providers participating in the Neighborhood network are required to be enrolled with Rhode Island Medicaid. If you are currently not enrolled with Rhode Island Medicaid, please visit the Rhode Island Executive Office of Health and Human Services Provider Enrollment Page for additional information on how to enroll: Rhode Island Medicaid Provider Enrollment Application.
18. Please provide the following information for all practitioners providing services at the practice.*
Name NPI CAQH #
As an authorized representative of the practice indicated above, I have reviewed and attest to the best of my knowledge, the information provided on this Questionnaire is accurate and complete.
Authorized Individual (Name)*
Signature*
Signature Date*
MM slash DD slash YYYY
Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network.
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Name	NPI	CAQH #

Section 1: Provider Information

Section 2: Practice/Facility Information

Section 3: Other Provider Information

Primary Care Participation Questionnaire: