ࡱ>  q` bjbjqPqP .::D\\\8T 43(. <D$*h'9$**9$9$'4VVV9$V9$VV:V,W Q?c \% W MW.Ɗ0W =WW0!L0"6Vf","!!!''UX!!!9$9$9$9$ New Jersey Universal Physician Application (Please type or print) SECTION 1Personal InformationPhysician Name (Last) (First) (MI) (Jr., Sr., etc.)  FORMTEXT      Professional Degree(s) (MD, DO, DDS, DMD, DPM, DC)  FORMTEXT      Social Security Number  FORMTEXT      Other Name Used  FORMTEXT      Years Associated with Former Name  FORMTEXT      Other Name Used  FORMTEXT      Years Associated with Former Name  FORMTEXT      Date of Birth (mm/dd/yyyy)  FORMTEXT       /  FORMTEXT       /  FORMTEXT      Gender  FORMCHECKBOX  Male  FORMCHECKBOX  FemaleAre you eligible to work in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoHome Mailing Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Practice Location InformationType of Service Provided  FORMCHECKBOX  Primary Care Specialist  FORMCHECKBOX  Non-Primary Care SpecialistPhysician Group Name/Practice Name (to appear in the directory)  FORMTEXT      Group/Corporate Name (as it appears on W-9), if different from Group Name/Practice Name  FORMTEXT      Primary Office Mailing Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Primary Office Telephone No.  FORMTEXT      Primary Office Fax No.  FORMTEXT      Primary Office E-mail Address  FORMTEXT      Tax ID Number and Associated Individual Group Number and Name for This Location  FORMTEXT      Are you currently practicing at the above location?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf No, what is your expected start date?  FORMTEXT      Other Office Street Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Telephone No.  FORMTEXT      Fax No.  FORMTEXT      E-mail Address  FORMTEXT      Do you want this site listed in the Directory?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoTax ID Number and Associated Individual Group Number and Name for This Location  FORMTEXT      Other Office Street Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Telephone No.  FORMTEXT      Fax No.  FORMTEXT      E-mail Address  FORMTEXT      Do you want this site listed in the Directory?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoTax ID Number and Associated Individual Group Number and Name for This Location  FORMTEXT      Correspondence Office Street Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Telephone No.  FORMTEXT      Fax No.  FORMTEXT      E-mail Address  FORMTEXT      If you have additional offices, please submit an attachment containing the above information and check this box:  FORMCHECKBOX  NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) License and Other Identification Numbers (License Information - Include all license(s) and certifications in all States where you are currently or have previously been licensed.)TypeState(s) of RegistrationDo You Currently Practice In This State?License/Certificate NumberExpiration DateN/ALicense  FORMTEXT       FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT       FORMTEXT      License  FORMTEXT       FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT       FORMTEXT      DEA Registration Certificate  FORMTEXT       FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT       FORMTEXT      CDS Registration Certificate  FORMTEXT       FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT       FORMTEXT      Other (CDS/DEA) (Specify)  FORMTEXT       FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT       FORMTEXT      UPIN  FORMTEXT      National Provider ID (when available)  FORMTEXT      Are you a participating Medicare Provider?  FORMTEXT      Medicare Provider No.  FORMTEXT      Are you a participating Medicaid Provider?  FORMTEXT      Medicaid Provider No.  FORMTEXT      International Medical Graduates: Are you certified by the Educational Council for Foreign Medical Graduates (ECFMG)?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, ECFMG Number  FORMTEXT      ECFMG Issue Date  FORMTEXT      Medical EducationSchool Issuing Professional Degree (Medical, Dental, Chiropractic)  FORMTEXT      Degree  FORMTEXT      Attendance Dates  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State/Country  FORMTEXT      Zip Code  FORMTEXT      If you have attended additional schools, please submit an attachment containing the above information and check this box:  FORMCHECKBOX  Post-Graduate Education  FORMCHECKBOX  Internship  FORMCHECKBOX  Fellowship  FORMCHECKBOX  Residency  FORMCHECKBOX  Teaching AppointmentInstitution Name  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Specialty  FORMTEXT      Start Date (Month/Year)  FORMTEXT      End Date (Month/Year)  FORMTEXT      Post-Graduate Education  FORMCHECKBOX  Internship  FORMCHECKBOX  Fellowship  FORMCHECKBOX  Residency  FORMCHECKBOX  Teaching AppointmentInstitution Name  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Specialty  FORMTEXT      Start Date (Month/Year)  FORMTEXT      End Date (Month/Year)  FORMTEXT      Post-Graduate Education  FORMCHECKBOX  Internship  FORMCHECKBOX  Fellowship  FORMCHECKBOX  Residency  FORMCHECKBOX  Teaching AppointmentInstitution Name  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Specialty  FORMTEXT      Start Date (Month/Year)  FORMTEXT      End Date (Month/Year)  FORMTEXT      If you completed additional training, please submit an attachment containing the above information and check this box:  FORMCHECKBOX  Other Graduate Level Education for Which a Degree Was Obtained - Type of Program (Psychology, Public Health, MBA, etc.)  FORMTEXT      Institution Name  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Degree Obtained  FORMTEXT      Date of Graduation (Month/Year)  FORMTEXT      NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) Professional/Medical Specialty InformationPrimary Specialty  FORMTEXT      Board Certified?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoName of Certifying Board  FORMTEXT      Initial Certification Date  FORMTEXT      Recertification Date (s) (if applicable)  FORMTEXT      Expiration Date (if applicable)  FORMTEXT      Do you wish to be listed in the directory under this specialty? HMO  FORMCHECKBOX  Yes  FORMCHECKBOX  No PPO  FORMCHECKBOX  Yes  FORMCHECKBOX  No POS  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf not Board Certified, indicate any of the following that apply: FORMCHECKBOX  I have taken exam, results pending for: FORMTEXT      (board) FORMCHECKBOX  I am intending to sit for the Boards on: FORMTEXT      (date) FORMCHECKBOX  I am not planning to take the Boards.Secondary Specialty  FORMTEXT      Board Certified?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoName of Certifying Board  FORMTEXT      Initial Certification Date  FORMTEXT      Recertification Date (s) (if applicable)  FORMTEXT      Expiration Date (if applicable)  FORMTEXT      Do you wish to be listed in the directory under this specialty? HMO  FORMCHECKBOX  Yes  FORMCHECKBOX  No PPO  FORMCHECKBOX  Yes  FORMCHECKBOX  No POS  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf not Board Certified, indicate any of the following that apply: FORMCHECKBOX  I have taken exam, results pending for: FORMTEXT      (board) FORMCHECKBOX  I am intending to sit for the Boards on: FORMTEXT      (date) FORMCHECKBOX  I am not planning to take the Boards.Additional Specialty  FORMTEXT      Board Certified?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoName of Certifying Board  FORMTEXT      Initial Certification Date  FORMTEXT      Recertification Date (s) (if applicable)  FORMTEXT      Expiration Date (if applicable)  FORMTEXT      Do you wish to be listed in the directory under this specialty? HMO  FORMCHECKBOX  Yes  FORMCHECKBOX  No PPO  FORMCHECKBOX  Yes  FORMCHECKBOX  No POS  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf not Board Certified, indicate any of the following that apply: FORMCHECKBOX  I have taken exam, results pending for: FORMTEXT      (board) FORMCHECKBOX  I am intending to sit for the Boards on: FORMTEXT      (date) FORMCHECKBOX  I am not planning to take the Boards.List Additional Areas of Professional Practice, Interest or Focus (HIV/AIDS, etc.)  FORMTEXT      Hospital Affiliations and PrivilegesDo you have hospital privileges?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf you do not admit patients, what admitting arrangements do you have?  FORMTEXT      If you have privileges, please complete the section below. Include all hospitals where you have privileges.Primary Hospital where you have Admitting Privileges  FORMTEXT      Telephone Number  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Full Unrestricted Privileges  FORMCHECKBOX  Yes  FORMCHECKBOX  NoType of Privileges  FORMTEXT      Are Privileges Temporary?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoOf the total admissions to all hospitals in the past year, what percentage is to this specific hospital?  FORMTEXT      Other Hospital Where you Have Privileges  FORMTEXT      Telephone Number  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Full Unrestricted Privileges  FORMCHECKBOX  Yes  FORMCHECKBOX  NoType of Privileges  FORMTEXT      Are Privileges Temporary?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoOf the total admissions to all hospitals in the past year, what percentage is to this specific hospital?  FORMTEXT      Other Hospital Where you Have Privileges  FORMTEXT      Telephone Number  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Full Unrestricted Privileges  FORMCHECKBOX  Yes  FORMCHECKBOX  NoType of Privileges  FORMTEXT      Are Privileges Temporary?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoOf the total admissions to all hospitals in the past year, what percentage is to this specific hospital?  FORMTEXT      Additional Hospital Where you Have Privileges  FORMTEXT      Telephone Number  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Full Unrestricted Privileges  FORMCHECKBOX  Yes  FORMCHECKBOX  NoType of Privileges  FORMTEXT      Are Privileges Temporary?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoOf the total admissions to all hospitals in the past year, what percentage is to this specific hospital?  FORMTEXT      If you have additional hospital affiliations, please submit an attachment containing the above information and check this box:  FORMCHECKBOX  NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) List all other hospitals where you have previously had privileges.Hospital Name  FORMTEXT      Dates of Affiliation  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Hospital Name  FORMTEXT      Dates of Affiliation  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      If you have other previous hospital affiliations, please submit an attachment containing the above information and check this box:  FORMCHECKBOX  Work HistoryInclude chronological work history since completion of training.Practice/Employer Name  FORMTEXT      Start Date/End Date  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Practice/Employer Name  FORMTEXT      Start Date/End Date  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Practice/Employer Name  FORMTEXT      Start Date/End Date  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Practice/Employer Name  FORMTEXT      Start Date/End Date  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      For additional work history, please submit an attachment containing the above information and check this box:  FORMCHECKBOX  Please provide an explanation of any gaps greater than six months in each work history.Date  FORMTEXT      Explanation  FORMTEXT      Date  FORMTEXT      Explanation  FORMTEXT      Are you currently on active military duty or on military reserve?  FORMCHECKBOX  Yes  FORMCHECKBOX  No ReferencesPlease provide three professional references that are not partners in your own group practice and are not relatives.NameStreet Address City, State, Zip Code FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) Professional Liability Insurance CoverageAre you self-insured?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoName of Current Malpractice Insurance Carrier or Self-Insured Entity  FORMTEXT      Telephone Number  FORMTEXT      Effective Date  FORMTEXT      Expiration Date  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Policy Number  FORMTEXT      Amount of Coverage per Occurrence  FORMTEXT      Amount of Coverage Aggregate  FORMTEXT      Type of Coverage  FORMCHECKBOX  Individual  FORMCHECKBOX  SharedLength of Time with Carrier  FORMTEXT      Name of Previous Malpractice Insurance Carrier or Self-Insured Entity  FORMTEXT      Telephone Number  FORMTEXT      Effective Date  FORMTEXT      Expiration Date  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Policy Number  FORMTEXT      Amount of Coverage per Occurrence  FORMTEXT      Amount of Coverage Aggregate  FORMTEXT      Type of Coverage  FORMCHECKBOX  Individual  FORMCHECKBOX  SharedLength of Time with Carrier  FORMTEXT       Status/Role in Practice FORMCHECKBOX  Owner  FORMCHECKBOX  Partner  FORMCHECKBOX  Employee  FORMCHECKBOX  Officer  FORMCHECKBOX  Shareholder Interests in Outside Clinical Lab(s)If you own/co-own, or have interests in any other outside clinical lab, please fill in below:Legal Billing Name  FORMTEXT      TIN (Attach copy of W-9)  FORMTEXT      Clinical Description  FORMTEXT      Please provide a summary pattern for this business:  FORMTEXT       Office CoverageList names of colleague(s) providing regular coverage and his/her specialty(ies).NameProvider Specialty FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       PartnersList full names of all partners in your practice (attach list for large group).Name (Last, First, MI)Name (Last, First, MI) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) Other Practice Information (specify for each site)Site 1Site 2Office Address:  FORMTEXT      Office Address:  FORMTEXT      Type of Practice:  FORMCHECKBOX Solo  FORMCHECKBOX Single Specialty Group  FORMCHECKBOX Multi-Specialty GroupType of Practice:  FORMCHECKBOX Solo  FORMCHECKBOX Single Specialty Group  FORMCHECKBOX Multi-Specialty GroupOffice Manager or Business Office Staff Contact::Office Manager or Business Office Staff Contact::Name: FORMTEXT      Name: FORMTEXT      Telephone No.: FORMTEXT      Telephone No.: FORMTEXT      Fax No.: FORMTEXT      Fax No.: FORMTEXT      Credentialing Contact (if different from above):Credentialing Contact (if different from above):Name: FORMTEXT      Name: FORMTEXT      Telephone No.: FORMTEXT      Telephone No.: FORMTEXT      Fax No.: FORMTEXT      Fax No.: FORMTEXT      E-mail: FORMTEXT      E-mail: FORMTEXT      Address: FORMTEXT      Address: FORMTEXT      City: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Billing Information:Billing Information:Billing Rep. Name: FORMTEXT      Billing Rep. Name: FORMTEXT      Address: FORMTEXT      Address: FORMTEXT      City: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No.: FORMTEXT      Telephone No.: FORMTEXT      Fax No.: FORMTEXT      Fax No.: FORMTEXT      E-mail: FORMTEXT      E-mail: FORMTEXT      Dept. Name if Hosp.-Based: FORMTEXT      Dept. Name if Hosp.-Based: FORMTEXT      Check should be payable toCheck should be payable to FORMTEXT       FORMTEXT      Do you have capability of electronic billing?  FORMCHECKBOX Yes  FORMCHECKBOX NoDo you have capability of electronic billing?  FORMCHECKBOX Yes  FORMCHECKBOX NoOffice Business Hours (hours patients are seen):Office Business Hours (hours patients are seen):DayNo Office HoursMorningAfternoonEveningDayNo Office HoursMorningAfternoonEveningMON FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      MON FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      TUES FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      TUES FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      WED FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      WED FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      THUR FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      THUR FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      FRI FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      FRI FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      SAT FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      SAT FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      SUN FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      SUN FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      After hours, back office phone number for health plan business use only:  FORMTEXT      After hours, back office phone number for health plan business use only:  FORMTEXT      Do you provide 24 hour/7 day a week phone coverage for this site?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, indicate type:  FORMCHECKBOX  Answering service  FORMCHECKBOX  Voice mail with instructions to call answering service  FORMCHECKBOX  Voice mail with other instructionsDo you provide 24 hour/7 day a week phone coverage for this site?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, indicate type:  FORMCHECKBOX  Answering service  FORMCHECKBOX  Voice mail with instructions to call answering service  FORMCHECKBOX  Voice mail with other instructions(Continue on next page.) NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) Other Practice Information (specify for each site)(Continued from previous page.) Site 1, ContinuedSite 2, ContinuedDo you accept new patients into the practice?  FORMCHECKBOX Yes  FORMCHECKBOX No -All new patients?  FORMCHECKBOX Yes  FORMCHECKBOX No -Existing patients with change of payor?  FORMCHECKBOX Yes  FORMCHECKBOX No -New patients from physician referral?  FORMCHECKBOX Yes  FORMCHECKBOX No -New Medicare patients?  FORMCHECKBOX Yes  FORMCHECKBOX No -New Medicaid patients?  FORMCHECKBOX Yes  FORMCHECKBOX NoDo you accept new patients into the practice?  FORMCHECKBOX Yes  FORMCHECKBOX No -All new patients?  FORMCHECKBOX Yes  FORMCHECKBOX No -Existing patients with change of payor?  FORMCHECKBOX Yes  FORMCHECKBOX No -New patients from physician referral?  FORMCHECKBOX Yes  FORMCHECKBOX No -New Medicare patients?  FORMCHECKBOX Yes  FORMCHECKBOX No -New Medicaid patients?  FORMCHECKBOX Yes  FORMCHECKBOX NoIf this information varies by health plan, provide explanation:  FORMTEXT      If this information varies by health plan, provide explanation:  FORMTEXT      Are there any practice limitations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, indicate limitations below:Are there any practice limitations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, indicate limitations below:Gender:  FORMCHECKBOX Male Only  FORMCHECKBOX Female Only  FORMCHECKBOX N/AGender:  FORMCHECKBOX Male Only  FORMCHECKBOX Female Only  FORMCHECKBOX N/APatient Age Limitation (List Ages):  FORMCHECKBOX N/APatient Age Limitation (List Ages):  FORMCHECKBOX N/A FORMTEXT       FORMTEXT      List Other Limitations:List Other Limitations: FORMTEXT       FORMTEXT      Do mid-level practitioners such as nurse practitioners, physician assistants, midwives, social workers or other non-physician providers care for patients in your practice?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, provide the following information for each staff member:Do mid-level practitioners such as nurse practitioners, physician assistants, midwives, social workers or other non-physician providers care for patients in your practice?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, indicate limitations below:Name: FORMTEXT      Name: FORMTEXT      Professional Designation: FORMTEXT      Professional Designation: FORMTEXT      State License Number: FORMTEXT      State License Number: FORMTEXT      Name: FORMTEXT      Name: FORMTEXT      Professional Designation: FORMTEXT      Professional Designation: FORMTEXT      State License Number: FORMTEXT      State License Number: FORMTEXT      Please attach a list of any additional mid-level practitioners.Please attach a list of any additional mid-level practitioners.Non-English Languages spoken:Non-English Languages spoken:by health care professional: FORMTEXT      by health care professional: FORMTEXT      by office personnel: FORMTEXT      by office personnel: FORMTEXT      Are interpreters available?  FORMCHECKBOX Yes  FORMCHECKBOX NoAre interpreters available?  FORMCHECKBOX Yes  FORMCHECKBOX NoIf yes, specify languages:If yes, specify languages: FORMTEXT       FORMTEXT      Does this office meet ADA accessibility standards?  FORMCHECKBOX Yes  FORMCHECKBOX NoDoes this office meet ADA accessibility standards?  FORMCHECKBOX Yes  FORMCHECKBOX NoDoes this site provide handicapped accessibility for each of the following: Building  FORMCHECKBOX Yes  FORMCHECKBOX No Parking  FORMCHECKBOX Yes  FORMCHECKBOX No Restroom  FORMCHECKBOX Yes  FORMCHECKBOX NoDoes this site provide handicapped accessibility for each of the following: Building  FORMCHECKBOX Yes  FORMCHECKBOX No Parking  FORMCHECKBOX Yes  FORMCHECKBOX No Restroom  FORMCHECKBOX Yes  FORMCHECKBOX NoOther: FORMTEXT      Other: FORMTEXT      Does this site have other services for the disabled?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, indicate type: Text Telephony - TTY  FORMCHECKBOX Yes  FORMCHECKBOX No American Sign Language-ASL  FORMCHECKBOX Yes  FORMCHECKBOX No Mental/Physical Impairment Services  FORMCHECKBOX Yes  FORMCHECKBOX NoDoes this site have other services for the disabled?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, indicate type: Text Telephony - TTY  FORMCHECKBOX Yes  FORMCHECKBOX No American Sign Language-ASL  FORMCHECKBOX Yes  FORMCHECKBOX No Mental/Physical Impairment Services  FORMCHECKBOX Yes  FORMCHECKBOX NoOther: FORMTEXT      Other: FORMTEXT      (Continue on next page.) NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) Other Practice Information (specify for each site)(Continued from previous page.) Site 1, ContinuedSite 2, ContinuedIs this site accessible by public transportation?  FORMCHECKBOX Yes  FORMCHECKBOX No Bus  FORMCHECKBOX Yes  FORMCHECKBOX No Subway  FORMCHECKBOX Yes  FORMCHECKBOX No Regional Train  FORMCHECKBOX Yes  FORMCHECKBOX NoIs this site accessible by public transportation?  FORMCHECKBOX Yes  FORMCHECKBOX No Bus  FORMCHECKBOX Yes  FORMCHECKBOX No Subway  FORMCHECKBOX Yes  FORMCHECKBOX No Regional Train  FORMCHECKBOX Yes  FORMCHECKBOX NoOther: FORMTEXT      Other: FORMTEXT      Does this site provide childcare services?  FORMCHECKBOX Yes  FORMCHECKBOX NoDoes this site provide childcare services?  FORMCHECKBOX Yes  FORMCHECKBOX NoDoes this office qualify as a minority business enterprise?  FORMCHECKBOX Yes  FORMCHECKBOX NoDoes this office qualify as a minority business enterprise?  FORMCHECKBOX Yes  FORMCHECKBOX NoDo you or does someone in your office have the following certifications? (Indicate for each office location.)Do you or does someone in your office have the following certifications? (Indicate for each office location.) Yes No Exp.Date Yes No Exp.DateBLS (Basic Life Support) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      BLS (Basic Life Support) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      ACLS (Advanced Cardiac Life Support) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      ACLS (Advanced Cardiac Life Support) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      ALSO (Advanced Life Support in OB) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      ALSO (Advanced Life Support in OB) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      PALS (Pediatric Advanced Life Support) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      PALS (Pediatric Advanced Life Support) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      ATLS (Advanced Trauma Life Support) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      ATLS (Advanced Trauma Life Support) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      NALS (Neonatal Advanced Life Support) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      NALS (Neonatal Advanced Life Support) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      CPR (Cardio-Pulmonary Resuscitation) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      CPR (Cardio-Pulmonary Resuscitation) FORMCHV. 0 D F H R T V   ( * ȿܯ|qܯ^|ܯK$jvh 5CJOJQJU$jh 5CJOJQJUh 6CJOJQJ)jh 5CJOJQJUmHnHu$jh 5CJOJQJUh 5CJOJQJjh 5CJOJQJUh 5OJQJh CJOJQJh CJOJQJh OJQJh 5CJOJQJh >*CJ(OJQJV|okd$$IfTH)0*  &04 Hap &T$If$xha$$a$ . 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(Indicate for each office location.)Does your site provide any of the following services on site? (Indicate for each office location.)Laboratory Services  FORMCHECKBOX Yes  FORMCHECKBOX NoLaboratory Services  FORMCHECKBOX Yes  FORMCHECKBOX NoCertificate of Participation from CLIA or another accrediting/certifying program [AAFP, COLA, CAP, Medical Laboratory Evaluation (MLE)] Program  FORMCHECKBOX Yes  FORMCHECKBOX NoCertificate of Participation from CLIA or another accrediting/certifying program [AAFP, COLA, CAP, Medical Laboratory Evaluation (MLE)] Program  FORMCHECKBOX Yes  FORMCHECKBOX NoIf yes, list program: FORMTEXT      If yes, list program: FORMTEXT      Radiology Services  FORMCHECKBOX Yes  FORMCHECKBOX NoRadiology Services  FORMCHECKBOX Yes  FORMCHECKBOX NoX-Ray Certification  FORMCHECKBOX Yes  FORMCHECKBOX NoX-Ray Certification  FORMCHECKBOX Yes  FORMCHECKBOX NoIf yes, include type: FORMTEXT      If yes, include type: FORMTEXT      EKG s  FORMCHECKBOX Yes  FORMCHECKBOX NoEKG s  FORMCHECKBOX Yes  FORMCHECKBOX NoCare of Minor Lacerations  FORMCHECKBOX Yes  FORMCHECKBOX NoCare of Minor Lacerations  FORMCHECKBOX Yes  FORMCHECKBOX NoPulmonary Function Testing  FORMCHECKBOX Yes  FORMCHECKBOX NoPulmonary Function Testing  FORMCHECKBOX Yes  FORMCHECKBOX NoAllergy Injections  FORMCHECKBOX Yes  FORMCHECKBOX NoAllergy Injections  FORMCHECKBOX Yes  FORMCHECKBOX NoAllergy Skin Testing  FORMCHECKBOX Yes  FORMCHECKBOX NoAllergy Skin Testing  FORMCHECKBOX Yes  FORMCHECKBOX NoOffice Gynecology (Routine Pelvic/Pap)  FORMCHECKBOX Yes  FORMCHECKBOX NoOffice Gynecology (Routine Pelvic/Pap)  FORMCHECKBOX Yes  FORMCHECKBOX NoDrawing Blood  FORMCHECKBOX Yes  FORMCHECKBOX NoDrawing Blood  FORMCHECKBOX Yes  FORMCHECKBOX NoAge Appropriate Immunizations  FORMCHECKBOX Yes  FORMCHECKBOX NoAge Appropriate Immunizations  FORMCHECKBOX Yes  FORMCHECKBOX NoFlexible Sigmoidoscopy  FORMCHECKBOX Yes  FORMCHECKBOX NoFlexible Sigmoidoscopy  FORMCHECKBOX Yes  FORMCHECKBOX NoTympanometry/Audiometry Screening  FORMCHECKBOX Yes  FORMCHECKBOX NoTympanometry/Audiometry Screening  FORMCHECKBOX Yes  FORMCHECKBOX NoAsthma Treatment  FORMCHECKBOX Yes  FORMCHECKBOX NoAsthma Treatment  FORMCHECKBOX Yes  FORMCHECKBOX NoOsteopathic Manipulation  FORMCHECKBOX Yes  FORMCHECKBOX NoOsteopathic Manipulation  FORMCHECKBOX Yes  FORMCHECKBOX NoIV Hydration/Treatment  FORMCHECKBOX Yes  FORMCHECKBOX NoIV Hydration/Treatment  FORMCHECKBOX Yes  FORMCHECKBOX NoCardiac Stress Tests  FORMCHECKBOX Yes  FORMCHECKBOX NoCardiac Stress Tests  FORMCHECKBOX Yes  FORMCHECKBOX NoPhysical Therapy  FORMCHECKBOX Yes  FORMCHECKBOX NoPhysical Therapy  FORMCHECKBOX Yes  FORMCHECKBOX NoAdditional Office Procedures Provided (incl. surgical procedures)  FORMTEXT      Additional Office Procedures Provided (incl. surgical procedures)  FORMTEXT      Is anesthesia administered in your office?  FORMCHECKBOX Yes  FORMCHECKBOX No If Yes, what class or category of anesthesia do you use?Is anesthesia administered in your office?  FORMCHECKBOX Yes  FORMCHECKBOX No If Yes, what class or category of anesthesia do you use? FORMTEXT       FORMTEXT      Who administers it?Who administers it? FORMTEXT       FORMTEXT      For additional office sites, please submit an attachment containing the above information and check this box:  FORMCHECKBOX  NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) Patient SchedulingWhat is patient wait time for emergency care?  FORMTEXT      What is patient wait time for urgent care?  FORMTEXT      What is patient wait time for symptomatic care?  FORMTEXT      What is patient wait time for scheduling routine visits?  FORMTEXT      What is patient wait time for scheduling routine care?  FORMTEXT      What is average wait time for patients between waiting room and examination? FORMTEXT      What is average wait time in minutes for returning a patient s call?  FORMTEXT       Required Attachments or Supplemental InformationPlease attach hard copy or scanned documents of the following: Copy(ies) of DEA registration certificate(s) Copy of state Controlled Dangerous Substance (CDS) registration certificate(s) Copy of current professional liability insurance policy face sheet, showing expiration dates, limits and provider s name Copy(ies) of W-9(s) for verification of each tax identification number used Copy of workers compensation certificate of coverage, if applicable SECTION 2 - DISCLOSURE QUESTIONSPlease answer each question and include an explanation for any question answered  Yes. Licensure1. Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation or have you ever been subject to a consent order, probation or any conditions or limitations by any state licensing board?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 2. Have you ever received a reprimand or been fined by any state licensing board?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoHospital Privileges and Other Affiliations3. Have your clinical privileges at any hospital or healthcare institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 4. Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 5. 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)?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoEducation, Training and Board Certification6. Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 7. Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 8. Have any of your board certifications or eligibility ever been revoked?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 9. Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) DEA or CDS Certification/Authorization10. Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s) or authorization(s) ever been denied, suspended, revoked, restricted, denied renewal, or voluntarily relinquished?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoMedicare, Medicaid or Other Governmental Program Participation11. Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified, subject to a recovery action or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoOther Sanctions or Investigations12. Are you currently or have you ever been the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 13. To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 14. Have you ever received sanctions from or been the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 15. Has a patient, employee, or co-worker ever accused you of sexual harassment or other illegal misconduct that resulted in an investigation, sanction or other formal action?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 16. Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation by a hospital or healthcare facility of any military agency?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoProfessional Liability Insurance Information and Claims History17. Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 18. Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional liability insurance carrier, based on your individual liability history?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoMalpractice Claims History19. Have you ever had any malpractice actions (pending, settled, dropped, dismissed, arbitrated, mediated or litigated)? If yes, provide information for each case on the attached form located at the end of the Disclosure questions (list all separately).  FORMCHECKBOX  Yes  FORMCHECKBOX  No For any malpractice actions, please complete addendum and check this box:  FORMCHECKBOX Criminal/Civil History (Note: A criminal record will not necessarily be a bar to acceptance. Decisions will be made by each health plan or credentialing organization based upon all relevant circumstances, including the nature of the crime.)20. Have you ever been arrested, charged or indicted for, convicted of, pled guilty to, or pled nolo contendere to any felony, crime or other offense in the last ten years or been found liable or responsible for or named as a defendant in any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 21. Have you ever been arrested, charged or indicted for, convicted of, pled guilty to, or pled nolo contendere to any felony, crime or other offense in the last ten years or been found liable or responsible for or been named as a defendant in any civil offense that alleged fraud, an act of violence, child abuse or a sexual offense or sexual misconduct?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 22. Have you ever been court-martialed for actions related to your duties as a medical professional?  FORMCHECKBOX  Yes  FORMCHECKBOX  No NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) Ability to Perform Job23. 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 on one 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 application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct.  Illegal use of drugs 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 authorized by the Controlled Substances Act or other provision of Federal law. The term does include, however, the unlawful use of prescription controlled substances.)  FORMCHECKBOX  Yes  FORMCHECKBOX  No 24. Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 25. Do you have any reason to believe that you would pose a risk to the safety or well being of your patients?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 26. Are you able to perform the essential functions of a practitioner in your area of practice with or without reasonable accommodation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Please provide information below for Malpractice Actions indicated for Disclosure Question #19.Date of occurrence: FORMTEXT      Date claim was filed: FORMTEXT      Claim/case status: FORMTEXT       FORMTEXT      Professional liability carrier involved: FORMTEXT      Address: FORMTEXT      Telephone Number: FORMTEXT      Policy Number: FORMTEXT      Amount of award or settlement and amount paid: FORMTEXT      Method of resolution: FORMCHECKBOX Dismissed  FORMCHECKBOX Settled (with prejudice)  FORMCHECKBOX Settled (without prejudice)  FORMCHECKBOX Judgment for defendant(s)  FORMCHECKBOX Judgment for plaintiff(s)  FORMCHECKBOX Mediation or arbitrationDescription of allegations: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Were you primary defendant or co-defendant? FORMTEXT      Number of other co-defendants: FORMTEXT      Your involvement in case (attending, consulting, etc.): FORMTEXT      Description of alleged injury to the patient: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      To the best of your knowledge, is this case included in the National Practitioner Data Bank (NPDB)?  FORMCHECKBOX Yes  FORMCHECKBOX No NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) Please provide information below for any Disclosure Questions in Section II answered  Yes. Question No.Explanation FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Provider Initials: FORMTEXT      Date: FORMTEXT       NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) SECTION 3 - AUTHORIZATION, ATTESTATION AND RELEASE I understand and agree that, as part of the credentialing application process for participation and/or clinical privileges (hereinafter, referred to as  Participation ) at or with FORMTEXT      (indicate managed care company(s) to which you are applying) (hereinafter, individually referred to as the  Entity ), and any of the Entity s affiliated entities, I am required to 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, employees, 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 understand that 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 contract with 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 that acceptance of my application by the Entity will not result in my employment by the Entity. Authorizations Investigation Concerning Application for Participation: I hereby authorize the following individuals including, without limitation, the Entity, its representatives, employees, and/or designated agent(s); the Entity s affiliated entities and their representatives, employees, and/or designated agents; and the Entity's designated 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 all records and documents relating to such an investigation. 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, health maintenance organizations, managed care organizations, law enforcement or licensing agencies, insurance companies, educational and other institutions, military services, medical credentialing and accreditation agencies, professional medical societies, the Federation of State Medical Boards, the National Practitioner Data Bank, and the Health Care Integrity and Protection Data Bank, to release to the Entity and/or its Agent(s), information, including otherwise privileged or confidential information, concerning my professional qualifications, credentials, clinical competence, quality assurance and utilization data, character, mental condition, physical condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing on my qualifications for Participation 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 currently pending against me. I specifically waive written notice from any entities and individuals who provide information based upon this Authorization, Attestation and Release. Release and Exchange of Disciplinary Information: I hereby further authorize any third party at which I currently have Participation or had Participation 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 the Agent(s) to release Disciplinary Information about any disciplinary action taken against me to its participating Entities at which I have Participation, and as may be otherwise required by law. As used herein,  Disciplinary Information means information concerning: (i) any action taken by such health care organizations, their administrators, or their medical or other committees to revoke, deny, suspend, restrict, or condition my Participation or impose a corrective action plan; (ii) any other disciplinary action involving me, including, but not limited to, discipline in the employment context; or (iii) my resignation prior to the conclusion of any disciplinary proceedings 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. Provider Initials: FORMTEXT      Date: FORMTEXT       NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued) Releases 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 without 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 such Entity, 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 immunities 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 other third party include their respective employees, directors, officers, advisors, counsel, and agents. The Entity or any of its affiliates or agents retains the right to allow access 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 the credentialing processes and provided that the customer and/or their auditor executes an appropriate confidentiality agreement. I understand and agree that this Authorization, 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 or health 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 authorization. I understand that my failure to promptly provide another consent may be grounds for termination or discipline by the Entity in accordance with the applicable bylaws, 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 in accordance with the provisions of this Authorization, Attestation and Release is not and will not be a violation of my privacy. Attestation I certify that all information provided by me in my application is true, correct, and complete to the best of my knowledge and belief, and that I will notify the Entity and/or its Agent(s) within 10 days of any material changes to the information I have provided in my application or authorized to be released pursuant to the 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 be submitted on-line or in writing, and must be dated and signed by me (may be a written or an electronic signature). I understand and agree that the information provided on this application may be shared with appropriate State and federal agencies. I understand and agree that any material misstatement or omission in the application may constitute grounds for withdrawal of the application from consideration; denial or revocation of Participation; and/or immediate suspension or termination of Participation. This action may be disclosed to the Entity and/or its Agent(s). I further understand and agree that submitting false, misleading or incomplete information may result in the imposition of administrative, civil and/or criminal sanctions, in accordance with State and federal law. I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release. I understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original. 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