APPLICATION TO JOIN THE EQUALITY HEALTH NETWORK
PRACTICE IDENTIFICATION INFORMATION Practice Legal Name (Per W-9): FORMTEXT ????? FORMTEXT DBA (Identifying) Name: FORMTEXT ?????Practice Type: FORMCHECKBOX Primary Care FORMCHECKBOX Pediatrics FORMCHECKBOX Specialist FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Multi-Specialty FORMCHECKBOX Urgent Care FORMCHECKBOX Behavioral HealthSpanish Speaking Availability: FORMCHECKBOX Yes FORMCHECKBOX NoMalpractice Carrier: FORMTEXT ?????Tax Identification Number (TIN): FORMTEXT ????? Group National Provider Identifier (NPI): FORMTEXT ?????Correspondence Address: FORMTEXT ????? FORMTEXT Ste: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Pay to / Remit Address: FORMTEXT ????? FORMTEXT Ste: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Phone: FORMTEXT ????? FORMTEXT FORMTEXT Fax: FORMTEXT FORMTEXT FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ????? FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT PRACTICE CONTACT INFORMATIONNamePhoneEmail AddressPrimary Contact: FORMTEXT ????? FORMTEXT ????? FORMTEXT FORMTEXT FORMTEXT FORMTEXT ?????Lead Provider: FORMTEXT FORMTEXT FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Credentialing Contact: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PRACTICE INFORMATIONElectronic Medical Records FORMCHECKBOX Yes FORMCHECKBOX No Certified Electronic Medical FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX 2011 FORMCHECKBOX 2014 FORMCHECKBOX 2015 Name of EMR: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Version of EMR: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????E- Prescribing: FORMCHECKBOX Yes FORMCHECKBOX No E-Charting: FORMCHECKBOX Yes FORMCHECKBOX No Active Patient Portal: FORMCHECKBOX Yes FORMCHECKBOX NoOnline Scheduling: FORMCHECKBOX Yes FORMCHECKBOX No Health Information Exchange: FORMCHECKBOX Yes FORMCHECKBOX NoDisease Registry: FORMCHECKBOX Yes FORMCHECKBOX NoDirect E-mail: FORMCHECKBOX Yes FORMCHECKBOX NoE-mail Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CCD-A: FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently participating in an Accountable Care Organization (ACO)? FORMCHECKBOX Yes FORMCHECKBOX No Name of the ACO: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX MSSP Track 1 FORMCHECKBOX MSSP Track 2 FORMCHECKBOX MSSP Track 3 FORMCHECKBOX Next GenerationDid you successfully attest to MIPS? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX ACI FORMCHECKBOX IA FORMCHECKBOX QPP Year _______Do you participate with other networks? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX ACN – Arizona Care Network FORMCHECKBOX ACO Partner FORMCHECKBOX ASPA – Arizona State Physicians Association FORMCHECKBOX Banner – Neighborhood Physicians Alliance FORMCHECKBOX PCCN – Phoenix Children’s Care Network FORMCHECKBOX Steward Health Care Network FORMCHECKBOX OTHER: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PRACTICE INFORMATIONPatient Centered Medical Home (PCMH): FORMCHECKBOX Yes FORMCHECKBOX NoFederally Qualified Health Center (FQHC): FORMCHECKBOX Yes FORMCHECKBOX NoIntegrated Clinic Designation (IC): FORMCHECKBOX Yes FORMCHECKBOX NoAre all providers Board Certified? FORMCHECKBOX Yes FORMCHECKBOX NoIf not, please explain: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do you have a process to identify gaps in care? FORMCHECKBOX Yes FORMCHECKBOX No Do you have a dedicated IT resource/consultant? FORMCHECKBOX Yes FORMCHECKBOX NoBILLING INFORMATIONPractice Management System: FORMCHECKBOX Yes FORMCHECKBOX NoName and Version of PM System: FORMTEXT ?????Name of Clearinghouse: FORMTEXT ?????Do you outsource your billing? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please provide name of billing agency: Billing Contact Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Billing Contact Number: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do you accept assignment with Medicaid: FORMCHECKBOX Yes FORMCHECKBOX NoPlease select which AHCCCS plans you participate in: FORMCHECKBOX Arizona Complete Health FORMCHECKBOX Banner – University Family Care FORMCHECKBOX Care 1st FORMCHECKBOX Magellan Health Services FORMCHECKBOX Mercy Care FORMCHECKBOX Steward Health Choice FORMCHECKBOX UHC Community (APIPA) FORMCHECKBOX Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do you accept assignment with Medicare: FORMCHECKBOX Yes FORMCHECKBOX NoPlease select which Medicare plans you participate in: FORMCHECKBOX Aetna Medicare FORMCHECKBOX Allwell FORMCHECKBOX BCBS of Arizona Advantage FORMCHECKBOX Bright Health FORMCHECKBOX Care 1st+ FORMCHECKBOX CareMore Health Plan of Arizona FORMCHECKBOX Cigna FORMCHECKBOX UnitedHealthcare FORMCHECKBOX Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ADDITIONAL INFORMATIONHow were you referred to Equality Health? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Application Completed by: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Date: FORMTEXT ????? FORMTEXT ?????DOCUMENTSPlease include the following documents with your completed application:Delegation Agreement for each Physician AssistantGeneral LiabilityList of Health Plans acceptedProfessional Liability Insurance / Certificate of Malpractice Insurance for each ProviderW-9 (must be current)PRACTICE LOCATIONSLocation Code: 01Practice Location Street: FORMTEXT FORMTEXT FORMTEXT FORMTEXT ????? Primary Location FORMCHECKBOX Ste: FORMTEXT ????? City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Handicap Accessible: FORMCHECKBOX Yes FORMCHECKBOX NoPhone: FORMTEXT ????? Fax: FORMTEXT ????? After Hours: FORMCHECKBOX Yes FORMCHECKBOX NoDays and Hours of Operation: FORMTEXT MondayTuesdayWednesdayThursdayFridaySaturdaySundayOpen: AM PMOpen: AM PMOpen: AM PMOpen: AM PMOpen: AM PMOpen: AM PMOpen: AM PMClose: AM PMClose: AM PMClose: AM PMClose: AM PMClose: AM PMClose: AM PMClose: AM PMLocation Code: 02Practice Location Street: FORMTEXT FORMTEXT FORMTEXT FORMTEXT ????? Ste: FORMTEXT ????? City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Handicap Accessible: FORMCHECKBOX Yes FORMCHECKBOX NoPhone: FORMTEXT ????? Fax: FORMTEXT ????? After Hours: FORMCHECKBOX Yes FORMCHECKBOX NoDays and Hours of Operation:MondayTuesdayWednesdayThursdayFridaySaturdaySundayOpen: AM PMOpen: AM PMOpen: AM PMOpen: AM PMOpen: AM PMOpen: AM PMOpen: AM PMClose: AM PMClose: AM PMClose: AM PMClose: AM PMClose: AM PMClose: AM PMClose: AM PMPROVIDER ROSTERProvider Name: FORMTEXT ????? FORMTEXT FORMTEXT Degree: FORMTEXT ????? Gender: FORMCHECKBOX M FORMCHECKBOX FLocation Code: FORMTEXT ?????Email: FORMTEXT ?????NPI: FORMTEXT ????? FORMTEXT CAQH ID: FORMTEXT ?????License Number: FORMTEXT ?????Specialty: FORMTEXT ?????Board Certified: FORMCHECKBOX Yes FORMCHECKBOX NoMalpractice Carrier: FORMTEXT ?????Other Languages Spoken: FORMCHECKBOX No FORMCHECKBOX Yes, Languages: Accepts New Patients: FORMCHECKBOX Yes FORMCHECKBOX NoHospital Privileges: FORMCHECKBOX Yes, Facility: FORMTEXT ????? FORMCHECKBOX No, Arrangements: FORMTEXT ????? FORMTEXT ?????Provider Name: FORMTEXT ?????Degree: FORMTEXT ????? Gender: FORMCHECKBOX M FORMCHECKBOX FLocation Code: FORMTEXT ?????Email: FORMTEXT ?????NPI: FORMTEXT ?????CAQH ID: FORMTEXT ?????License Number: FORMTEXT ?????Specialty: FORMTEXT ?????Board Certified: FORMCHECKBOX Yes FORMCHECKBOX NoMalpractice Carrier: FORMTEXT ?????Other Languages Spoken: FORMCHECKBOX No FORMCHECKBOX Yes, Languages: FORMTEXT ?????Accepts New Patients: FORMCHECKBOX Yes FORMCHECKBOX NoHospital Privileges: FORMCHECKBOX Yes, Facility: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No, Arrangements: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Provider Name: FORMTEXT ?????Degree: FORMTEXT ????? Gender: FORMCHECKBOX M FORMCHECKBOX FLocation Code: FORMTEXT ?????Email: FORMTEXT ?????NPI: FORMTEXT ?????CAQH ID: FORMTEXT ?????License Number: FORMTEXT ?????Specialty: FORMTEXT ?????Board Certified: FORMCHECKBOX Yes FORMCHECKBOX NoMalpractice Carrier: FORMTEXT ?????Other Languages Spoken: FORMCHECKBOX No FORMCHECKBOX Yes, Languages: FORMTEXT ?????Accepts New Patients: FORMCHECKBOX Yes FORMCHECKBOX NoHospital Privileges: FORMCHECKBOX Yes, Facility: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No, Arrangements: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Provider Name: FORMTEXT ?????Degree: FORMTEXT ????? Gender: FORMCHECKBOX M FORMCHECKBOX FLocation Code: FORMTEXT ?????Email: FORMTEXT ?????NPI: FORMTEXT ????? FORMTEXT ?????CAQH ID: FORMTEXT ?????License Number: FORMTEXT ?????Specialty: FORMTEXT ?????Board Certified: FORMCHECKBOX Yes FORMCHECKBOX NoMalpractice Carrier: FORMTEXT ?????Other Languages Spoken: FORMCHECKBOX No FORMCHECKBOX Yes, Languages: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Accepts New Patients: FORMCHECKBOX Yes FORMCHECKBOX NoHospital Privileges: FORMCHECKBOX Yes, Facility: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No, Arrangements: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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