Addendum Cover Page for Maryland Medical … Enrollment Application...Addendum for Participation in...

Addendum Cover Page for Maryland Medical Assistance Program Application

INDIVIDUAL PT 14 DENTAL

If you have questions, please contact the Provider Enrollment Helpline at 1-844-4MD-PROV (1-844-463-7768) Monday – Friday from 7am – 7pm.

All providers are required to use the electronic Provider Revalidation and Enrollment Portal, or ePREP (eprep.health.maryland.gov) for enrollment, information updates, provider affiliations and revalidations.

Please fill out the information below and upload the completed addendum to the “Additional Information” section under “Practice Information” within the ePREP (eprep.health.maryland.gov) “Applications” tab, along with any additional documents requested within the addendum.

Provider Information

NPI:

SSN:

MA Provider Number (if already enrolled in Maryland Medicaid):

Please visit health.maryland.gov/ePREP for more information about ePREP

of 22 V1 2018 effective 02/27/2018 PT 14 DENTAL

https://eprep.health.maryland.gov/sso/login.do


https://mmcp.health.maryland.gov/Pages/ePREP.aspx

Addendum for Participation in Maryland Medical Assistance Program Application


If you have questions, please contact the Provider Enrollment Helpline at 1-844-4MD-PROV (1-844-463-7768) Monday – Friday from 7am – 7pm.

Please upload this form to the “Additional Information” section under “Practice Information” within the ePREP (eprep.health.maryland.gov) “Applications” tab, along with any additional applicable supporting documents requested below.

Section I: Please upload the following documents to ePREP :

1. Completed Provider Plan Participation for Maryland Healthy Smiles form

2. Completed Standard Authorization, Attestation and Release form

3. Completed Credentialing form

If you should have any questions regarding the above items, please contact the Scion Dental Credentialing Team at (855) 812-9211 or at Credentialing @ScionDental.com

Section II: Please upload the following documents to ePREP :

1. Completed W-9 form

2. Completed Electronic Funds Transfer (EFT) form if you wish to receive payments via direct deposit.

If you should have any questions regarding the above items, please contact the Scion Dental Network Development Team at (800) 508-6965 or at Network Development @ScionDental.com

Section III: Please respond to the question below:

1. Are you rendering services in an FQHC?

YES NO

• If yes, please provide the name, Maryland Medical Assistance Provider Number, and NPI of the FQHC in whichyou render services:







FQHC Name: __________________________________________________________________

Maryland Medical Assistance Provider Number: ________________________________

NPI: ________________________________


Provider Plan Participation for Maryland Healthy Smiles

The Maryland Healthy Smiles Dental Program (Maryland Healthy Smiles) provides coverage for

children under the age of 21, pregnant women 21 years of age and older, and adults enrolled in

the Rare and Expensive Case Management (REM) program. SKYGEN USA administers the

Maryland Healthy Smiles Program.

Please select the coverage plans in the Maryland Healthy Smiles Program which your office accepts:

Maryland Healthy Smiles Child – Participants are children in the Maryland Medicaid program, ages 0-

20.

REM Child - The Rare and Expensive Case Management (REM) Program is a case managed, fee-for-

service alternative to HealthChoice Managed Care Organization (MCO). Participation is only for

recipients with specified rare and expensive conditions. Participants are ages 0 – 20.

REM Adult - The Rare and Expensive Case Management (REM) Program is a case managed, fee-for-

service alternative to HealthChoice Managed Care Organization (MCO). Participation is only for

recipients with specified rare and expensive conditions. Participants are age 21 and older.

Pregnant Women – Participants are pregnant women who are age 21 and older.

Please check the box that applies:

Yes No

Are you currently accepting new Patients?

Is the office handicap accessible?

Is the office able to assist special needs patients?

Does the office provide in office sedation?

Does your office have age restrictions?

If yes please provide: Age minimum:____ Age maximum:____

Does your office accept continuation of care cases that were started by a different

provider?

Office/Group Name: ________________________________ Address: ______________________

Tax ID: _________________________________________

NPI: ___________________________

Practicing Providers: ________________________________________________________________

Person completing form: ___________________________ Office Ph#: ________________________

of 22

Please select the office location type:

General Office

Mobile Unit

Medical Center

Please select the specialties that the office location treats: (check all that apply)

General Endodontics Prosthodontics

Pediatric Periodontics Oral Surgery

Orthodontics Orthodontic Continuation of Care Cases

of 22

Standard Authorization, Attestation and ReleaseI understand and agree that, as part of the credentialing application process for participation, membership and/or clinical privileges (hereinafter, referred to as"Participation") at or with each healthcare organization indicated on the "List of Authorized Organizations" that accompanies this Provider Application (hereinafter,each healthcare organization on the "List of Authorized Organizations" is individually referred to as the "Entity"), and any of the Entity's affiliated entities, I am requiredto provide sufficient and accurate information for a proper evaluation of my current licensure, relevant training and/or experience, clinical competence, health status,character, ethics, and any other criteria used by the Entity for determining initial and ongoing eligibility for Participation. Each Entity and its representatives, employ -ees, and agent(s) acknowledge that the information obtained relating to the application process 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 understandthat 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 contractwith me as a provider of services. I understand that my application for Participation with the Entity is not an application for employment with the Entity and thatacceptance of my application by the Entity will not result in my employment by the Entity.

Authorization of Investigation Concerning Application for Participation. I authorize the following individuals including, without limitation, the Entity, its representa-tives, employees, and/or designated agent(s); the Entity's affiliated entities and their representatives, employees, and/or designated agents; and the Entity's designat -ed professional credentials verification organization (collectively referred to as "Agents"), to investigate information, which includes both 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 and copy all records and documentsrelating to such an investigation.

Authorization of 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, healthmaintenance organizations, managed care organizations, law enforcement or licensing agencies, insurance companies, educational and other institutions, militaryservices, medical credentialing and accreditation agencies, professional medical societies, the Federation of State Medical Boards, the National Practitioner DataBank, and the Health Care Integrity and Protection Data Bank, to release to the Entity and/or its Agent(s), information, including otherwise privileged or confidentialinformation, concerning my professional qualifications, credentials, clinical competence, quality assurance and utilization data, character, mental condition, physicalcondition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing on my qualifications forParticipation 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 cur-rently pending against me. I specifically waive written notice from any entities and individuals who provide information based upon this Authorization, Attestation andRelease.

Authorization of Release and Exchange of Disciplinary Information. I hereby further authorize any third party at which I currently have Participation or hadParticipation and/or each third party's agents to release "Disciplinary Information," as defined below, to the Entity and/or its Agent(s). I hereby further authorize theAgent(s) to release Disciplinary Information about any disciplinary action taken against me to its participating Entities at which I have Participation, and as may beotherwise required by law. As used herein, "Disciplinary Information" means information concerning (i) any action taken by such health care organizations, theiradministrators, or their medical or other committees to revoke, deny, suspend, restrict, or condition my Participation or impose a corrective action plan; (ii) any otherdisciplinary action involving me, including, but not limited to, discipline in the employment context; or (iii) my resignation prior to the conclusion of any disciplinary pro -ceedings or prior to the commencement of formal charges, but after I have knowledge that such formal charges were being (or are being) contemplated and/or were(or are) in preparation.

Release from Liability. I release from all liability and hold harmless any Entity, its Agent(s), and any other third party for their acts performed in good faith and with-out malice unless such acts are due to the gross negligence or willful misconduct of the Entity, its Agent(s), or other third party in connection with the gathering,release and exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release. I further agree not to sue any Entity,any Agent(s), or any other third party for their acts, defamation or any other claims based on statements made in good faith and without malice or misconduct of suchEntity, Agent(s) or third party in connection with the credentialing process. This release shall be in addition to, and in no way shall limit, any other applicable immuni-ties provided by law for peer review and credentialing activities. In this Authorization, Attestation and Release, all references to the Entity, its Agent(s), and/or otherthird party include their respective employees, directors, officers, advisors, counsel, and agents. The Entity or any of its affiliates or agents retains the right to allowaccess to the application information for purposes of a credentialing audit to customers and/or their auditors to the extent required in connection with an audit of thecredentialing processes and provided that the customer and/or their auditor executes an appropriate confidentiality agreement. I understand and agree that thisAuthorization, Attestation and Release is irrevocable for any period during which I am an applicant for Participation at an Entity, a member of an Entity's medical orhealth care staff, or a participating provider of an Entity. I agree to execute another form of consent if law or regulation limits the application of this irrevocable authori-zation. I understand that my failure to promptly provide another consent may be grounds for termination or discipline by the Entity in accordance with the applicablebylaws, rules, and regulations, and requirements of the Entity, or grounds for my termination of Participation at or with the Entity. I agree that information obtained inaccordance with the provisions of this Authorization, Attestation and Release is not and will not be a violation of my privacy.

I certify that all information provided by me in my application is current, true, correct, accurate and complete to the best of my knowledge and belief, and is furnishedin good faith. I will notify the Entity and/or its Agent(s) within 10 days of any material changes to the information (including any changes/challenges to licenses, DEA,insurance, malpractice claims, NPDB/HIPDB reports, discipline, criminal convictions, etc.) I have provided in my application or authorized to be released pursuant tothe credentialing process. I understand that corrections to the application are permitted at any time prior to a determination of Participation by the Entity, and must besubmitted online or in writing, and must be dated and signed by me (may be a written or an electronic signature). I acknowledge that the Entity will not process anapplication until they deem it to be a complete application and that I am responsible to provide a complete application and to produce adequate and timely informa-tion for resolving questions that arise in the application process. I understand and agree that any material misstatement or omission in the application may constitutegrounds for withdrawal of the application from consideration; denial or revocation of Participation; and/or immediate suspension or termination of Participation. Thisaction may be disclosed to the Entity and/or its Agent(s). I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Releaseand that I have access to the bylaws of applicable medical staff organizations and agree to abide by these bylaws, rules and regulations. I understand and agree thata facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.

Name (print)*Signature*

DATE SIGNED*


INDIVIDUAL

PT 14 DENTAL of 22

Education and Training

UndergraduateSchool(s)Provide the appropriateinformation for theschool that issued yourundergraduate degreeand all schoolsattended.

ProfessionalSchool(s)Provide the appropriateinformation for theschool that issued yourprofessional degree.

UNDERGRADUATE SCHOOL

DEGREE AWARDEDSTART DATE END DATE (GRADUATION DATE)

M M Y Y Y YM M Y Y Y Y

OFFICIAL NAME OF UNDERGRADUATE SCHOOL

DID YOU COMPLETE YOURUNDERGRADUATE EDUCATIONAT THIS SCHOOL?

YES NO

DID YOU COMPLETE YOURGRADUATE EDUCATION AT THISSCHOOL?

YES NO

DID YOU COMPLETE YOURGRADUATE EDUCATION AT THISSCHOOL?

YES NO

ADDRESS

CITY STATE ZIP/POSTAL CODE

COUNTRY CODE TELEPHONE

- -FAX

- -

DEGREE AWARDEDSTART DATE* END DATE (GRADUATION DATE)*


U.S. OR CANADIAN SCHOOL

NON - U.S. OR CANADIAN SCHOOL

CITY COUNTRY CODE POSTAL CODE

ADDRESS

DEGREE AWARDEDSTART DATE* END DATE (GRADUATION DATE)*


OFFICIAL NAME OF NON-U.S. PROFESSIONAL SCHOOL

SCHOOL CODE (U.S./CANADIAN ONLY)

NAME OF U.S./CANADIAN SCHOOL:

U.S. OR CANADIAN GRADUATE FIFTH PATHWAY GRADUATE

GRADUATE TYPE*:

NON-U.S./CANADIAN GRADUATE

If you have a CAQH number, please provide it here: __________________, and do not complete the following form.

If you do not have a CAQH number, please complete the following form.


INDIVIDUAL

PT 14 DENTAL of 22

Education and Training (Continued)

Training

List all trainingprograms youattended. Use onesection per institution. INSTITUTION/HOSPITAL NAME (USE BOTH LINES IF REQUIRED)

START DATE END DATE


SCHOOL CODE (E.G.,AFFILIATED MEDICALSCHOOL)

INTERNSHIP/RESIDENCY FELLOWSHIP OTHER

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

NAME OF DIRECTOR

NAME OF DIRECTOR

NAME OF DIRECTOR

List eachdepartment

separately, ifapplicable.

ListInternship/Residency,Fellowshipand Otherprograms

separately.INTERNSHIP/RESIDENCY FELLOWSHIP OTHER


START DATE END DATE


INTERNSHIP/RESIDENCY

FELLOWSHIP OTHER


START DATE END DATE


NUMBER STREET SUITE/BUILDING


COUNTRY CODE TELEPHONE

- -FAX

- -

DID YOU COMPLETE THIS TRAINING PROGRAM AT THISINSTITUTION?

(IF NOT, PLEASE USE THE SPACE BELOW TO EXPLAIN.)

YES NO


INDIVIDUAL

of 22

PT 14 DENTAL

PrimarySpecialty

SPECIALTY CODE

BOARD CERTIFIED? YES NO

CERTIFYING BOARD CODE

RECERTIFICATION DATE

(IF APPLICABLE)M M D D Y Y Y Y

EXPIRATION DATE (IF APPLICABLE) M M D D Y Y Y Y

INITIAL CERTIFICATION

DATE M M D D Y Y Y Y YES NO

DO YOU WISH TOBE LISTED INTHE DIRECTORYUNDER THISSPECIALTY?

YES NO

YES NO

HMO

PPO

POS

IF NOTBOARD CERTIFIED(SELECTONE)

I HAVE TAKENEXAM, RESULTSPENDING FOR


IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE A CERTIFYING BOARD EXAM, PLEASE USE THEFOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.

I INTEND TO SIT FOR ANEXAM ON

M M D D Y Y Y Y

I DO NOT INTEND TO TAKEA CERTIFYING BOARD EXAM.

IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE A CERTIFYING BOARD EXAM, PLEASE USE THEFOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.

Professional / Medical Specialty Information

SecondarySpecialty

SPECIALTY CODE

BOARD CERTIFIED?

YES NO


RECERTIFICATION DATE

(IF APPLICABLE)M M D D Y Y Y Y

EXPIRATION DATE (IF APPLICABLE) M M D D Y Y Y Y

INITIAL CERTIFICATION

DATE M M D D Y Y Y Y YES NO

DO YOU WISH TOBE LISTED INTHE DIRECTORYUNDER THISSPECIALTY?

YES NO

YES NO

HMO

PPO

POS

IF NOTBOARD CERTIFIED(SELECTONE)

I HAVE TAKENEXAM, RESULTSPENDING FOR


I INTEND TO SIT FOR ANEXAM ON

M M D D Y Y Y Y

I DO NOT INTEND TO TAKEA CERTIFYING BOARD EXAM.


INDIVIDUAL

of 22 PT 14 DENTAL

Office Hours

NOTE:

After hours back officetelephone will be usedonly by the health planand will not bepublished under anycircumstances.

(USE HHMM FORMAT AND ROUND TO THE NEAREST HALF-HOUR)

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

START END

24/7 PHONE COVERAGE?*

YES NO ANSWERINGSERVICE

IF YES

VOICE MAIL WITH INSTRUCTIONS TO CALLANSWERING SERVICE

VOICE MAIL WITH OTHERINSTRUCTIONS

AFTER HOURS BACK OFFICE TELEPHONE

- -

A=AMP=PM

A=AMP=PM

START ENDA=AMP=PM

A=AMP=PM

Open PracticeStatus

ACCEPT NEW PATIENTS INTO THIS PRACTICE?* YES NO

ACCEPT EXISTING PATIENTS WITH CHANGE OF PAYOR?*

IF ANY OF THEABOVE INFORMATIONVARIES BY PLAN,EXPLAIN (USE BOTHLINES IF REQUIRED)

YES NO

ACCEPT NEW PATIENTS WITH PHYSICIAN REFERRAL?*

ACCEPT NEW MEDICARE PATIENTS?*

ACCEPT NEW MEDICAID PATIENTS?* YES NO

ARE THERE ANYPRACTICE LIMITATIONS?*

YES NO

MALE ONLY

FEMALEONLY

NONEIF YES

YES NO

GENDER LIMITATIONS

MINIMUM AGE

MAXIMUM AGE

AGE LIMITATIONS LIST OTHER LIMITATIONS

YES NO

ACCEPT ALL NEW PATIENTS?* YES NO


INDIVIDUAL

Office Information

of 22 PT 14 DENTAL

Practice Location Information (Continued)

Languages

Accessibilities

Services

NON-ENGLISH LANGUAGES SPOKEN BY OFFICE PERSONNEL

LANGUAGE CODE LANGUAGE CODE LANGUAGE CODE LANGUAGE CODE LANGUAGE CODE

LANGUAGES INTERPRETED

LANGUAGE CODE LANGUAGE CODE LANGUAGE CODE LANGUAGE CODE

INTERPRETERSAVAILABLE?*

YES NO

LANGUAGES

DOES THIS OFFICE MEET ADA ACCESSIBILITY REQUIREMENTS?* YES NO

YES NO YES NODOES THIS SITE OFFER HANDICAPPED ACCESS FOR THE FOLLOWING

DOES THIS SITE OFFER OTHER SERVICES FOR THE DISABLED?*

ACCESSIBLE BY PUBLIC TRANSPORTATION?*

BUILDING?* YES NO

PARKING?* YES NO

RESTROOM?* YES NO

OTHER HANDICAPPED ACCESS

BUS* YES NO

SUBWAY* YES NO

REGIONAL TRAIN* YES NO

OTHER TRANSPORTATION ACCESS

TEXT TELEPHONY (TTY)* YES NO

AMERICAN SIGN LANGUAGE* YES NO

MENTAL/PHYSICAL IMPAIRMENTSERVICES*

YES NO

OTHER DISABILITY SERVICES

RADIOLOGYSERVICES? YES NO

LABORATORYSERVICES?

YES NOIF YES, PROVIDE ACCREDITING/CERTIFYING PROGRAM(E.G., CLIA, COLA, MLE)

IF YES, PROVIDE X-RAYCERTIFICATION TYPE

IF YES, WHATCLASS/CATEGORYDO YOU USE?

IF YES, WHOADMINISTERS IT?

IS ANESTHESIAADMINISTERED INYOUR OFFICE?

YES NO

Does this location provide any of the following services?

LAST NAME FIRST NAME

TYPE OF PRACTICE(SELECT ONE ONLY)* SOLO PRACTICE SINGLE SPECIALTY GROUP MULTI-SPECIALTY GROUP

ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)


INDIVIDUAL

of 22

THIS SECTION INTENTIONALLY LEFT BLANK

PT 14 DENTAL

ProfessionalLiabilityInsuranceCarrier

Professional Liability Insurance Carrier

SELF-INSURED? YES NO

CARRIER OR SELF-INSURED NAME

ProfessionalLiabilityInsuranceCarrierList other current,future, or previouscarrier(s) if currentcarrier is less than ten(10) years.

NOTE: A longer periodmay be required byyour healthcare entity.

SELF-INSURED?* YES NO

CARRIER OR SELF-INSURED NAME*

NUMBER* STREET* SUITE/BUILDING

EFFECTIVE DATE* EXPIRATION DATE


DO YOU HAVE UNLIMITED COVERAGEWITH THIS INSURANCE CARRIER?*

YES NO

DO YOU HAVE UNLIMITED COVERAGEWITH THIS INSURANCE CARRIER?

YES NO

POLICY INCLUDES TAIL COVERAGE? YES NO

, ,$

AMOUNT OF COVERAGE PER OCCURRENCE, ,

$AMOUNT OF COVERAGE AGGREGATE

POLICY INCLUDES TAIL COVERAGE? YES NO

, ,$

AMOUNT OF COVERAGE PER OCCURRENCE, ,

$AMOUNT OF COVERAGE AGGREGATE

STATE* ZIP CODE*CITY*

POLICY NUMBER*

POLICY NUMBER*

ORIGINAL EFFECTIVE DATE*

M M Y Y Y Y


EFFECTIVE DATE* EXPIRATION DATE

M M Y Y Y YM M Y Y Y Y TYPE OFCOVERAGE?*

INDIVIDUAL SHARED

TYPE OFCOVERAGE?*

INDIVIDUAL SHARED


ORIGINAL EFFECTIVE DATE*

M M Y Y Y Y

Work History and References

Work HistoryInclude a chronologicalwork history for thepast 10 years.

A longer period may berequired by yourhealthcare entity.

WORK HISTORY

PRACTICE / EMPLOYER NAME

Military Duty

Are you currently on active militaryduty or military reserve?* YES NO




INDIVIDUAL

of 22 PT 14 DENTAL

Work History and References (Continued)

Work History

Include a chronologicalwork history for thepast 10 years.

A longer period may berequired by yourhealthcare entity

START DATECOUNTRY CODE

REASON FOR DEPARTURE (IF APPLICABLE)

END DATE


TELEPHONE

- -FAX

- -



END DATE


TELEPHONE

- -FAX

- -






END DATE


TELEPHONE

- -FAX

- -




WORK HISTORY

WORK HISTORY


INDIVIDUAL

of 22 PT 14 DENTAL

Work History and References (Continued)

Gaps inProfessional /Work History

GAP START DATE

PLEASE EXPLAIN ANY TIME PERIODS OR GAPS IN TRAINING OR WORK HISTORY THAT HAVE OCCURRED SINCE GRADUATION FROM PROFESSIONAL SCHOOL AND ARELONGER THAN THREE MONTHS IN DURATION OR OF A SHORTER DURATION IF REQUIRED BY THE ORGANIZATION FOR WHICH YOU ARE BEING CREDENTIALED.

GAP END DATE M M Y Y Y YM M Y Y Y Y

LAST NAME*

FIRST NAME*

NUMBER* STREET* APT/SUITE/BUILDING



LAST NAME*

FIRST NAME*

LAST NAME*

FIRST NAME*

PROVIDER TYPE (CODE PG 36)






TELEPHONE

- -FAX

- -

TELEPHONE

- -FAX

- -

TELEPHONE

- -FAX

- -

ProfessionalReferencesProvide threeprofessional referencesto whom you are notrelated or are notpartners in yourpractice.

NOTE:

You are required toprovide exactly 3references. Yourapplication will not becomplete without thisinformation.


INDIVIDUAL

of 22 PT 14 DENTAL

Hospital Affiliations

Hospital

Privileges

If applicable, list allhospital affiliations. Listprimary hospital, thenother currentaffiliations, followed by

previous affiliations inchronological order.

If you have additionalhospital privileges, usethe Supplemental

Hospital PrivilegesForm on page 30.

TIP Be certain youradmission percentages

add up to 100% forcurrent hospitals.Otherwise, you willhave to correct thiserror.

PRIMARY HOSPITAL

HOSPITAL NAME

DEPARTMENT NAME


TELEPHONE

- -

FAX

- -

FULL, UNRESTRICTED

PRIVILEGES?

ARE PRIVILEGES

TEMPORARY?YES NO

ADMITTING PRIVILEGE STATUS (E.G. NONE, FULL UNRESTRICTED, PROVISIONAL, TEMPORARY)

ADMITTING PRIVILEGE STATUS (E.G. NONE, FULL UNRESTRICTED, PROVISIONAL, TEMPORARY)

OF YOUR TOTAL ANNUAL

ADMISSIONS, WHAT PERCENTAGEIS TO THIS HOSPITAL?

%

STATE ZIP CODECITY

YES NO

AFFILIATION START DATE

M M Y Y Y Y

OTHER HOSPITAL

HOSPITAL NAME

DEPARTMENT NAME


TELEPHONE

- -FAX

- -

OF YOUR TOTAL ANNUAL

ADMISSIONS, WHAT PERCENTAGEIS TO THIS HOSPITAL?

%

STATE ZIP CODECITY

AFFILIATION END DATE

M M Y Y Y Y

FULL, UNRESTRICTEDPRIVILEGES?

ARE PRIVILEGESTEMPORARY?

YES NOYES NO

AFFILIATION START DATE

M M Y Y Y Y

AFFILIATION END DATE

M M Y Y Y Y

PLEASE EXPLAIN

TERMINATED AFFILIATION

DEPARTMENT DIRECTOR’S LAST NAME

DEPARTMENT DIRECTOR’S FIRST NAME M.I.

DEPARTMENT DIRECTOR’S LAST NAME

DEPARTMENT DIRECTOR’S FIRST NAME M.I.

DO YOU HAVEHOSPITAL

PRIVILEGES?*

YES

of 22


INDIVIDUAL

NO

PT 14 DENTAL

Disclosure Questions

DisclosureQuestionsAnswer all questions.For any “Yes”response, provide anexplanation on theSupplementalDisclosure QuestionExplanation Form onpage 34.

Has your license, registration or certification to practice in your profession, ever been voluntarily or involuntarily relinquished,denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any con-ditions or limitations by any state or professional licensing, registration or certification board?*

YES NO1.

Has there been any challenge to your licensure, registration or certification?*YES NO2.

Have your clinical privileges or medical staff membership at any hospital or healthcare institution, voluntarily or involuntarily, everbeen denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (forreasons other than non-completion of medical record when quality of care was not adversely affected) or have proceedingstoward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee,or governing board?*

YES NO3.

Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?*YES NO4.

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, PHOs)?*

5.

LICENSURE

HOSPITAL PRIVILEGES AND OTHER AFFILIATIONS

Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, resi-dency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you beenplaced on probation, disciplined, formally reprimanded, suspended or asked to resign?*

YES NO6.

Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your statusas a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?*

YES NO7.

Have any of your board certifications or eligibility ever been revoked?*YES NO8.

EDUCATION, TRAINING AND BOARD CERTIFICATION

Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?*YES NO9.

Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s) or authorization(s) ever been chal-lenged, denied, suspended, revoked, restricted, denied renewal, or voluntarily or involuntarily relinquished?*

YES NO

DEA OR STATE CONTROLLED SUBSTANCE REGISTRATION

10.

Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or other-wise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmentalhealthcare plans or programs?*

YES NO

MEDICARE, MEDICAID OR OTHER GOVERNMENTAL PROGRAM PARTICIPATION

11.

YES NO

Are you currently the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing entities, educa-tion or training program, Medicare or Medicaid program, or any other private, federal or state health program or a defendantin any civil action that is reasonably related to your qualifications, competence, functions, or duties as a medical professionalfor alleged fraud, an act of violence, child abuse or a sexual offense or sexual misconduct?*

YES NO

OTHER SANCTIONS OR INVESTIGATIONS

12.

To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or HealthcareIntegrity and Protection Data Bank?*

YES NO13.

Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies (e.g., CLIA,OSHA, etc.)?*

YES NO14.

Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted, disciplined orresigned in exchange for no investigation or adverse action within the last ten years for sexual harassment or other illegalmisconduct?*

YES NO15.

Are you currently being investigated or have you ever been sanctioned, reprimanded, or cautioned by a military hospital, facility, oragency, or voluntarily terminated or resigned while under investigation or in exchange for no investigation by a hospital or health-care facility of any military agency?*

YES NO16.

Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on yourindividual liability history?*

YES NO

PROFESSIONAL LIABILITY INSURANCE INFORMATION AND CLAIMS HISTORY

17.

Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional liability insurancecarrier, based on your individual liability history?*

YES NO18.


INDIVIDUAL

of 22 PT 14 DENTAL

Disclosure Questions (Continued)

DisclosureQuestionsAnswer all questions.For any “Yes”response, provide anexplanation on theSupplementalDisclosure QuestionExplanation Form onpage 34.

IMPORTANTIf you answered “Yes” to question #19, you must complete the Supplemental Malpractice Claims Explanation.

Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony?*YES NO

CRIMINAL/CIVIL HISTORY

20.

In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minortraffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, compe-tence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offense or sexualmisconduct?*

YES NO21.

Have you ever been court-martialed for actions related to your duties as a medical professional?*YES NO22.

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 onone's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of applica-tion, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use ofdrugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22.It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses author-ized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use ofprescription controlled substances.)

YES NO

ABILITY TO PERFORM JOB

23.

Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the func-tions of your job with reasonable skill and safety?*

YES NO24.

Do you have any reason to believe that you would pose a risk to the safety or well being of your patients?*YES NO25.

Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonableaccommodation?*

YES NO26.

Have you had any professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past 10 years?*If yes, provide information for each case.

YES NO

MALPRACTICE CLAIMS HISTORY

19.

Note: A criminal record will not necessarily be a bar to acceptance. Decisions will be made by each health plan orcredentialing organization based upon all the relevant circumstances, including the nature of the crime.


INDIVIDUAL

of 22 PT 14 DENTAL

DisclosureQuestions

Use this form to reportany "Yes" response toone or more of theDisclosure Questionsin Section 8. Yourresponse should not exceed the spacesprovided.

Record the number in the first column, then your explanation in the second column.

Disclosure Questions

Question # Explanation:




INDIVIDUAL

of 22 PT 14 DENTAL

Malpractice Claims Explanation

MalpracticeClaimsExplanationUse this form to reportany “Yes” response toDisclosure Question#19.

If you need additionalspace to explain a Yesresponse, photocopythis page as neededand submit asinstructed.

STATUS OF CLAIM* (NOTE: IF CASE IS PENDING, SELECT OPEN)

DESCRIPTION OF ALLEGATIONS* (USE ALL FOUR LINES BELOW, IF NECESSARY)

PROFESSIONAL LIABILITY CARRIER INVOLVED* (USE BOTH LINES IF NECESSARY)


TELEPHONE

- -POLICY NUMBER

M M D D Y Y Y YDATE OFOCCURRENCE* M M D D Y Y Y YDATE CLAIM

WAS FILED*

M M D D Y Y Y Y

M M D D Y Y Y Y

IF SETTLED, ENTER DATECLAIM WAS SETTLED

, ,$

AMOUNT OF AWARD OR SETTLEMENT*

METHOD OFRESOLUTION?*

DISMISSED SETTLED MEDIATION

CLOSEDOPEN

JUDGMENT FORPLAINTIFF(S)

ARBITRATION

JUDGMENT FORDEFENDANT(S)

WERE YOU THE PRIMARYDEFENDANT OR CO-DEFENDANT?*

PRIMARYDEFENDANT CO-DEFENDANT NUMBER OF OTHER

CO-DEFENDANTS (IF ANY)

YOUR INVOLVEMENT IN CASE* (ATTENDING, CONSULTING, ETC)

TO THE BEST OF YOUR KNOWLEDGE, IS THE CASE INCLUDEDIN THE NATIONAL PRACTITIONER DATA BANK (NPDB)?*

YES NODID THE ALLEGED INJURYRESULT IN DEATH?

DESCRIPTION OF ALLEGED INJURY TO THE PATIENT (USE ALL FOUR LINES BELOW, IF NECESSARY)

YES NO


Application for Participation in Maryland Medical Assistance Program Application

INDIVIDUAL

of 22 PT 14 DENTAL

Electronic Funds Transfer (EFT) Authorization Agreement Get your reimbursement faster and easier with EFT! To receive your payments by EFT, please complete this form and return it with a scanned or faxed copy of a voided check. (This Authorization Agreement will not be valid without a voided check.)

Submission Options

Send this completed form and voided check to Scion Dental via: Fax: 262-721-0722 or Email: [email protected]

Submission Reason

Select one checkbox. ❑ New EFT Authorization | ❑ Account or bank change to existing EFT Authorization

Provider Information

Provider Name (Include d/b/a, if any.) Taxpayer Identification Number Select one checkbox. ❑ SSN | ❑ EIN

Street Address

City State Zip Code

Phone Number Email Address

Financial Institution Information

Financial Institution Name Financial Institution Routing Number (Include 9 digits with any leading zeros.)

Account Number (Include up to 10 digits with any leading zeros.) To indicate account type, select one checkbox. ❑ Checking Account | ❑ Savings Account

Note: Please return this form with a voided check or the Authorization Agreement will not be valid.

Authorization I agree to receive all vendor payments from the Scion Dental, Inc. by electronic funds transfer according to the terms of the EFT program. I agree to return to Scion Dental, Inc. any EFT payment incorrectly disbursed by Scion Dental, Inc. I agree to hold harmless Scion Dental, Inc. and its agencies and departments for any delays or errors caused by inaccurate or outdated registration information or by the financial institution listed above.

Printed Name Title

Authorized Signature Date

© 2017 Scion Dental, Inc. | CONFIDENTAL & PROPRIETARY | Electronic Funds Transfer (EFT) Authorization Agreement 2017.10v5

of 22

ELECTRONIC FUNDS TRANSFER (EFT) Terms of Use The following terms and conditions, as amended from time to time, (“Agreement”) apply to all use of the Scion Dental, Inc.'s (“Scion”) Electronic Funds Transfer solution, and the use of any service provided in connection therewith (collectively the “EFT Services”). In this Agreement, the words “you”, “your” and “yours” means the individual(s) entity or entities identified on the attached Electronic Fund Transfer (EFT) Authorization Agreement, and the words “we,” “our,” “us” refers to Scion affiliates and designees. Your enrollment or use of the EFT Services signifies your agreement to be legally bound by the terms and conditions set forth herein.

ACH and Wire Transfers. This Agreement is subject to Article 4A of the Uniform Commercial Code -- Funds Transfer. By signing this Agreement, you authorize Scion, acting directly or indirectly on behalf of or through, any third party administrator, health care coalition, or health plan carrier, or other third party carrier or payer (each a “Carrier”) that participates in the EFT Services, to credit or debit the account(s) listed on your Enrollment Form (the “Account” or “Accounts”) in connection with processing transactions between you and the Carrier. We may rely upon all Account information and identifying numbers provided by you on the Authorization Agreement to receive payment. We may rely on the routing and account numbers you provided even if they identify a financial institution, person or account other than the one named on the Enrollment Form. You agree to be bound by all applicable law, rules and guidelines related to electronic funds transfers, including, without limitation, 31 CFR Part 210, Article 4A of the UCC and the Automated Clearing House (ACH) Association Rules. The ACH rules provide, among other things, that payments made to you, or originated by you, are provisional until final settlement is made through a Federal Reserve Bank or payment is otherwise made as provided in Article 4A-403(a) of the UCC. If we do not receive such payment, we are entitled to a refund from you in the amount credited to your Account and the Carrier that originated or instructed such payment will not be considered to have paid the amount so credited. We are not required to give you any notice of debits or credits to your Accounts. We may make adjustments to your Accounts whenever a correction or change is required. For example, if we make an error with respect to your Account, you agree that we may correct such error immediately and without notice to you. Such errors may include, but are not limited to, reversing an improper credit to your Account, making adjustments for returned items, and correcting calculation and input errors. Our right to make adjustments shall not be subject to any limitations or time constraints, except as required by law.

Accounts. You represent and warrant that (a) you are the owner of each of the Accounts and (b) none of the Accounts is used primarily for personal, family or household purposes.

Disclosures of Account Information to Others. We may disclose information to third parties about you and your Account(s) and transactions as follows: (i) pursuant to agreements with third parties that assist us in the provision of EFT Services; (ii) to verify the existence and condition of an Account; and (iii) as otherwise necessary for us to provide services or facilitate payments to you.

Amendments and Termination. Scion may add, remove, change or otherwise modify any term of this Agreement at any time. We may also terminate or discontinue some or all of the EFT Services at any time without notice to you.

Governing Law and Venue. The laws of the State of Wisconsin shall govern this Agreement and all disputes arising hereunder. You hereby consent that jurisdiction and venue are proper in the State of Wisconsin for the resolution of any dispute arising under this Agreement.

Severability. If any provision of this Agreement is found to be unenforceable according to its terms, all remaining provisions will continue in full force and effect.

Cooperation. You agree to cooperate fully with us in furnishing any information, documentation or performing any action requested by us. You shall furnish us, upon forty-eight (48) hours’ notice, with true, accurate and complete copies of such records, documentation or any other information we or our authorized employees, representatives, agents and any regulatory agencies may request; provided, however, that you shall not be required to divulge any records to the extent prohibited by applicable law.

Ownership. Except as provided in this Agreement, Scion shall have and own all rights, title and interests in the EFT Services and any information arising from or in connection therewith. You hereby acknowledge the specific ownership interests of Scion as set forth herein and you shall not acquire any ownership rights by virtue of this Agreement.

Relationship of the Parties. The relationship between both parties under this Agreement is that of independent parties contracting at an arm’s-length with each other. Nothing herein contained shall be construed as constituting a partnership, joint venture or agency between the parties hereto.

Entire Agreement. This Agreement constitutes the only agreement between the parties hereto relating to the subject matter hereof, except where expressly noted herein, and all prior negotiations, agreements and understandings relating to the subject matter hereof, whether oral or written, are superseded or canceled hereby.

Force Majeure. Scion shall not be liable for a delay in performance or failure to perform any obligation under this Agreement to the extent such delay is due to causes beyond our control, including, but not limited to, governmental requests, regulations or orders, utility or communications failure, delays in transportation, national emergency, war, civil commotion or disturbance, war conditions, fires, floods, storms, earthquakes, tidal waves, failure or delay in receiving electronic data, equipment or systems failure or communication failures.

Warranties, Indemnification and Limitation of Liability. SCION HEREBY DISCLAIMS ALL WARRANTIES WITH RESPECT TO THE SERVICES AND PRODUCTS PROVIDED HEREUNDER, WHETHER EXPRESS, IMPLIED, STATUTORY OR OTHERWISE, INCLUDING, WITHOUT LIMITATION, ANY WARRANTY OF MERCHANTABILITY OR FITNESS FOR USE FOR A PARTICULAR PURPOSE. Scion is entering into this agreement as an accommodation and convenience to you, and you will indemnify and hold Scion free and harmless from and against any and all claims, demands, actions, suits damages and costs, whether groundless or otherwise, whether based on contract, negligence or otherwise, and as may arise out of any act or failure to act on the part of Scion. Scion shall incur no liability to you or any other person in the event the intended party does not receive the funds if Scion shall have acted reasonably in transmitting the funds in accordance with your instructions. Scion shall not be held liable or responsible for failures, delays, errors, claims or damages in the execution or effectuation of any transfer occasioned by the fault or negligence of any correspondent bank, agent, or agency for purposes of making or completing transfer of funds. IN NO EVENT SHALL SCION, ITS PARENT, AFFILIATES, SUBSIDIARIES, DIRECTORS, OFFICERS, EMPLOYEES, AGENTS OR REPRESENTATIVES BE LIABLE FOR SPECIAL, INCIDENTAL OR CONSEQUENTIAL DAMAGES OR CLAIMS BY YOU OR ANY THIRD PARTY RELATIVE TO THE TRANSACTIONS HERE UNDER.

of 22

Addendum Cover Page for Maryland Medical … Enrollment Application...Addendum for Participation in...

Documents

Transcript of Addendum Cover Page for Maryland Medical … Enrollment Application...Addendum for Participation in...