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.
  • Select date MM slash DD slash YYYY
  • Section 1: Provider Information

  • Include First Name, Middle Initial, and Last Name
  • 10 Digit Number
  • Section 2: Practice/Facility Information

  • (i.e., Director, CEO, etc.)
  • 10 Digit Number
  • Start with https://
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  • Section 3: Other Provider Information

  • Has the provider ever been excluded from participating with Medicare/Medicaid *
  • 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. *
  • 2. Practice provides diagnosis and treatment of acute and chronic conditions including but not limited to chronic lung disease, diabetes, and obesity. *
  • 3. Practice provides routine, yearly physical examinations in accordance to the American Academy of Pediatrics or other widely accepted adult guidelines (AAFP, CDC) *
  • 4. Practice provides all adult vaccinations per CDC guidelines. *
  • 5. Practice provides all pediatric vaccinations per CDC guidelines. *
  • 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. *
  • 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. *
  • 8. All practitioners are open to accepting new members. *
  • 9. Practice is open for 40 hours of appointment availability per week. *
  • 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? *
  • 11. Practice provides for expanded access on evenings and/or weekends. *
  • 12. Practice has an Appointment System that promotes and provides same-day access. *
  • 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. *
  • 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. *
  • 16. Practice is accredited by the National Committee for Quality Assurance (NCQA) *
  • 17. Practice and its practitioners are enrolled with Rhode Island Medicaid: *
  • NameNPICAQH # 
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  • 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.

  • Clear Signature
  • Select date MM slash DD slash YYYY
  • Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network.