Imaging Center – Credentialing – Assist Health Group

Step 1 of 5

20%

Diagnostic Imaging Center - Onboarding

Centers this applies to

Center Name

Facility Legal Name

Your Address

Street Address Address Line 2 City ZIP Code

TIN :

NPI # :

Contact (Scheduling):

Name :

Phone :

Fax :

Email :

Contact (Billing):

Name :

Phone :

Fax :

Email :

Contact (Management / Contracting):

Name :

Phone :

Fax :

Email :

Modalities Rendered At This Location :

MRI

Mammogram

Ultrasound

Xray

DEXA

Nuclear Studies

PET Scan

EKG

Holter Monitoring

EMG

Pulmonary Function Tests

Neurology Studies

Are you a mobile provider

If Yes, What Modalities? What Zip Codes?

Yes

Is This A Women's Imaging Only Facility?

Yes

Do You Have Another Location?

Yes

Add Another Form

MRI

Please Select

MRI Tesla Rating

MRI Bore Type

CT Scan

Please Select

CT Rating (Slices)

Mammogram

Please Select

Pathology Group Name

If Yes To Breast Biopsy, What Name?

Ultrasound

Please Select

Neurology

Please Select

Xray

Please Select

Other

Hida Scan?

Yes

Facility Credentialing Application

File

Drop files here or

Max. file size: 8 MB.

Contact

Name :

Email :

Phone Number :

Fax Number :

Legal Entity Information (Name on income tax return)

Contact

Tax ID Holder/ Facility Name :

NPI :

Federal Tax ID Number :

Fax :

Contact

Legal Tax Address (where you want the 1099 is sent) :

Ownership :

Contact

City :

State :

Zip :

Phone Number :

Legal Type

Service Location

Complete for each service location that is part of this application. (Must be street address, not a post office box)

Contact

Facility Name (to be displayed in the directory) :

Federal Tax ID Number :

State License Number :

Medicaid Number :

Contact

Medicare Number :

City :

State :

Zip :

Contact

County :

Main Switchboard Phone Number :

Service Location Fax Number :

Web Address :

Same as Legal NPI(s) :

Same as Legal Entity :

Service Location Address

Service Location Handicap Access? :

Yes

Service Location Accepting New Patients :

Yes

ADA Complaint (including offices, exam rooms and equipment)? :

Yes

Is American Sign Language Or Other Auxiliary Aid Services Available? :

Yes

Please List Any Foreign Languages Spoken At This Location :

Number Of Beds :

ECP Providers (Exchange/Commercial Only)

Are You Considered An Essential Community Provider As Defined By CMS?

Yes

Site Visit Requirement

Has The Department Of Human Services (DHS) Or A Government Agency Delegated By DHS?

Completed A Post-Licensing Onsite Survey Within The Past 36 Months?

(Yes) Date Of Most Recent Full Survey __________________

(No) Successful Completion Of A Health Plan Onsite Visit Will Be Required To Complete Credentialing.

Were Any Deficiencies Cited During The Last Survey??

(N/A) - No Recent Survey

If (NO), submit verification of no deficiencies.

If (YES), have all deficiencies been corrected?

If YES - Provide Evidence Of Acceptance Letter By DHS.

File

Drop files here or

Max. file size: 8 MB.

Please Indicate Type Of Organization

Choose All That Apply

LICENSURE *Provide Copy Of Licensure

File

Drop files here or

Max. file size: 8 MB.

Is The Facility Licensed By The State?

Yes

If Yes, Please Provide The Following Information Below :

Contact

Name (as it appears on license) :

License Number :

Expiration Date :

Date Of Most Recent CMS Survey :

Agency Name

List Below

Accreditation/Certification Type

Please provide a copy of these documents; including the Survey Results and a report that shows the effective or survey date of accreditation or certification or certification, deficiencies and approved corrective action plan.

Disclosure Questions & Sanctions

If yes, to any question below, please explain on a separate section labeled "Explain".

Have there been any settled malpractice claims, suits, settlements or proceedings involving your Organization within the past five years?

Yes

Has your Organization ever been disciplined, fine, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state government health care plans or programs?

Yes

Has an officer of your Organization ever been convicted of, pled guilty to, or pled "no lo contendere" to any felony including an act of violence, child abuse, or a sexual offense?

Yes

Has your Organization license ever been restricted, conditioned, suspended or terminated?

Yes

Does your Organization have any current state or federal sanctions or limitations?

Yes

Liability Insurance Coverage

Please provide your liability insurance coverage information below :

Carrier Name :

Single Occurrence Amount :

Aggregate Amount :

Beginning Date (Mo/Day/Yr) :

End Date (Mo/Day/Yr) :

Attestation

All information and documentation submitted here within is correct and complete to my best knowledge and belief. I acknowledge and understand that any material misstatements or omissions may constitute cause for denial of participation in the health plan. A copy of this original statement as signed by me shall have all the same force and effect as the signed original. I authorize Assist Health Corporation the right to obtain documents, recommendation, reports and statements relating to the Credentialing process of this facility and the associated facilities that intend to contract with the Assist Health Corporation. In addition, I also authorize the right to verify my standing with state and federal regulatory bodies relating to the Credentialing process.

Printed Name of Authorized Representative

Date

Signature

Date

Authorized Representative's Title

Date

Electronic Funds Transfer (EFT) Enrollment Form

Organization Information

Organization Name :

Organization Address :

City :

State :

Zip Code :

Organization Phone Number :

Tax Information

Tax ID Number :

Administrator Contract Information

First Name :

Last Name :

Email :

Phone Number :

Fax :

Bank Account Information

Legal Name on Bank Account :

Name of Financial Institution :

Routing Number :

Account Number :

Email Address For Notifications :

Account Type

Checking

Savings

Signature

Contact

Name :

Date :

W-9

Contact

Business Name:

Address :

Employer Identification Number :

Check The Approproate Box For Federal Tax Classification Of The Person Whose Name Is Entered On Line 1.

Check only one of the following seven boxes.

Individual/sole proprietor or single-member LLC

C Corporation

S Corporation

Partnership

Trust/Estate

Limited Liability Company.

Other

Phone

This field is for validation purposes and should be left unchanged.