Molina Healthcare of Florida, Inc. Practitioner Application

[Pages:13]Molina Healthcare of Florida, Inc. Practitioner Application

1. INSTRUCTIONS

This form should be:

? Typed or legibly printed in black or blue ink. ? Keep a copy of the application on file for future requests. ? If more space is needed than provided on original, attach additional sheets and reference the question being answered. ? Please do not use abbreviations. ? If a section does not apply to you, please check the provided box at the top of the section. ? If changes must be made to the completed application, strike out the information and write in the modification, initial and

date.

Please attach current copies of the following documents with this application:

? State Professional License(s) ? DEA Certificate ? ECFMG (if applicable) ? Please sign and date page 13 and answer the three

additional questions.

? Face Sheet of Professional Liability Policy or Certificate ? Curriculum Vitae (Not an acceptable substitute for

completing the application.)

** All sections must be completed in their entirety. **

Incomplete applications will be returned for completion prior to processing. Please return application and attachments to:

Molina Healthcare of Florida, Inc., ATTN: Provider Services Department, 8300 NW 33rd St, #400, Doral, FL 33122

2. PRACTITIONER INFORMATION Last Name: (include suffix; Jr., Sr., III)

First:

Middle:

Degree(s):

List any other name(s) under which you have been known by reference, licensing and or educational institutions:

Home Mailing Address:

City:

State:

Zip Code:

Home Telephone Number: ( )

Birth Date: (mm/dd/yyyy)

Pager Number/Cell Phone Number:

(

)

Birth Place (city, state, country):

E-Mail Address: Citizenship:

Social Security Number

Male Female

Languages spoken by Practitioner

Have you ever voluntarily opted-out of Medicare? Yes No

NPI:

Medicare UPIN:

Medicare Number:

Florida Medicaid Number: L & I Number(s):

Molina Healthcare of Florida, Inc. - Practitioner

Page 1 of 13

PRACTITIONER NAME:

Application

Modification to the wording or format of the Practitioner Application may invalidate the application.

Primary Practicing Specialty: Other Professional Interests in Practice, Research, etc.:

Other specialties:

3. PRIMARY PRACTICE INFORMATION Effective Date at Primary Practice location (MM/YY) __________

Practice Type (Please check all that apply) PCP Specialist Urgent Care Obstetrics

PCP and Obstetrics

Practice Setting

Clinic/Group Solo Practice

Home Based

Name of Practice / Affiliation or Clinic Name:

Hospital Based

Other________________________________

Department Name (if hospital based):

Primary Office Street Address:

Patient Appointment Telephone Number:

(

)

Mailing Address: (if different from above)

Billing Address: (if different from above)

Office Manager / Administrator Name: E-mail Address:

Credentialing Contact (if different from above):

E-mail Address:

Name Affiliated with Tax ID Number:

City:

State:

Zip Code:

Fax Number:

(

)

Org. NPI#:

Administration Telephone Number:

(

)

Fax Number:

(

)

Telephone Number:

(

)

Fax Number:

(

)

Federal Tax ID Number:

Is the office wheelchair accessible? Yes No If you are a PCP, do you provide OB services? Yes No

Are you accepting new patients? Yes No Have you limited your practice in any way (e.g. 18 years or older?)

Yes No If yes, please explain: _________________________________________________________ _________________________________________________________ Do you currently supervise ARNP's or PA's? Yes No If yes, please provide the name and specialty below: _________________________________________________________ _________________________________________________________ Please list languages spoken by office staff: _________________________________________________________ _________________________________________________________

Office Hours

Monday: ________________________ Tuesday: ________________________ Wednesday: ______________________ Thursday: ________________________ Friday: __________________________ Saturday: ________________________ Sunday:__________________________ Do you provide 24-hour coverage? Yes No If no, please explain how your patients obtain advice and care after hours: _________________________________________ _________________________________________ _________________________________________

Molina Healthcare of Florida, Inc. - Practitioner

Page 2 of 13

PRACTITIONER NAME:

Application

Modification to the wording or format of the Practitioner Application may invalidate the application.

4. ADDITIONAL PRACTICE INFORMATION

***Please make a copy of this page and complete for each additional location in which you practice

Effective Date at Primary Practice location (MM/YY) __________

Practice Type (Please check all that apply) PCP Specialist Urgent Care Obstetrics

PCP and Obstetrics

Practice Setting

Clinic/Group Solo Practice

Home Based Hospital Based

Other________________________________

Name of Secondary Practice / Affiliation or Clinic Name:

Department Name (if hospital based):

Primary Office Street Address:

Patient Appointment Telephone Number:

(

)

Mailing Address: (if different from above)

City:

State:

Zip Code:

Fax Number:

(

)

Org. NPI#

Billing Address: (if different from above)

Office Manager / Administrator Name: E-mail Address: Credentialing Contact (if different from above): E-mail Address: Name Affiliated with Tax ID Number:

Administration Telephone Number:

(

)

Fax Number:

(

)

Telephone Number:

(

)

Fax Number:

(

)

Federal Tax ID Number:

Is the office wheelchair accessible? Yes No If you are a PCP, do you provide OB services? Yes No

Are you accepting new patients? Yes No Have you limited your practice in any way (e.g. 18 years or older?)

Yes No If yes, please explain: _________________________________________________________ _________________________________________________________ Do you currently supervise ARNP's or PA's? Yes No If yes, please provide the name and specialty below: _________________________________________________________ _________________________________________________________ Please list languages spoken by office staff: _________________________________________________________ _________________________________________________________

Office Hours

Monday: ________________________ Tuesday: ________________________ Wednesday: ______________________ Thursday: ________________________ Friday: __________________________ Saturday: ________________________ Sunday:__________________________ Do you provide 24 hour coverage? Yes No If no, please explain how your patients obtain advice and care after hours: _________________________________________ _________________________________________ _________________________________________

Molina Healthcare of Florida, Inc. - Practitioner

Page 3 of 13

PRACTITIONER NAME:

Application

Modification to the wording or format of the Practitioner Application may invalidate the application.

5. PROFESSIONAL LICENSURE, REGISTRATIONS AND CERTIFICATIONS

(Attach Additional Sheet if Necessary)

Florida State Professional License/Registration/Cert Number:

Issue Date:

Name of Sponsor if required by licensure, (e.g. Physician's Assistant).

Drug Enforcement Administration (DEA) Registration Number: ECFMG Number (applicable to foreign medical graduates):

Expiration Date:

Expiration Date: Date Issued:

6. ALL OTHER PROFESSIONAL LICENSES, REGISTRATIONS AND CERTIFICATIONS

State:

Lic/Reg/Cert Number:

Date Issued Exp. Date

State:

Lic/Reg/Cert Number:

Date Issued Exp. Date

State:

Lic/Reg/Cert Number:

Date Issued Exp. Date

Yr. Relinquish Reason: Yr. Relinquish Reason: Yr. Relinquish Reason:

7. UNDERGRADUATE EDUCATION (Do not abbreviate)

College or University Name:

Degree Received(be specific, e.g. BS Biology)

Mailing Address:

City:

State:

Does Not Apply Graduation Date (mm/yyyy)

Zip Code:

College or University Name: Mailing Address:

Degree Received(be specific, e.g. BS Biology)

City:

State:

Graduation Date (mm/yyyy)

Zip Code:

8. MEDICAL/PROFESSIONAL EDUCATION (Do not abbreviate)

Medical/Professional School:

Start Date:

(mm/yyyy)

Mailing Address:

City:

Medical/Professional School: Mailing Address:

Start Date (mm/yyyy)

City:

Graduation Date (mm/yyyy)

State:

Graduation Date (mm/yyyy)

State:

Degree Received Zip Code: Degree Received Zip Code:

9. MASTER DEGREE PROGRAM OR POST GRADUATE EDUCATION

Institution:

Address

Dates Attended (mm/yyyy - mm/yyyy): Program or Course of Study:

(

/

) - (

/

)

Does Not Apply

City

State

Zip Code:

Faculty Director:

Molina Healthcare of Florida, Inc. - Practitioner

Page 4 of 13

PRACTITIONER NAME:

Application

Modification to the wording or format of the Practitioner Application may invalidate the application.

10. INTERNSHIP/PGYI Institution:

Mailing Address:

Type of Internship:

(Attach Additional Sheet if Necessary)

Phone Number:

Fax Number:

City:

State:

Specialty:

From (mm/yyyy):

Does Not Apply Program Director:

Zip Code:

To (mm/yyyy):

11. RESIDENCIES (Attach Additional Sheet if Necessary)

Institution:

Phone Number:

Mailing Address: Type of Residency:

City: Specialty:

Fax Number: State: From (mm/yyyy):

Does Not Apply Program Director:

Zip Code: To (mm/yyyy):

Did you successfully complete the program?

Yes

Institution:

Phone Number:

Mailing Address: Type of Residency:

City: Specialty:

No (If "No", please explain on separate sheet.)

Fax Number:

Program Director:

State: From (mm/yyyy):

Zip Code: To (mm/yyyy):

Did you successfully complete the program?

Yes

No (If "No", please explain on separate sheet.)

12. FELLOWSHIPS Institution:

(Attach Additional Sheet if Necessary)

Phone Number:

Fax Number:

Does Not Apply Program Director:

Mailing Address: Course of Study:

City:

State: From (mm/yyyy):

Zip Code: To (mm/yyyy):

Did you successfully complete the program? Institution:

Mailing Address: Course of Study:

Yes Phone Number:

City:

No (If "No", please explain on separate sheet.)

Fax Number:

Program Director:

State: From (mm/yyyy):

Zip Code: To (mm/yyyy):

Did you successfully complete the program?

Yes

No (If "No", please explain on separate sheet.)

Molina Healthcare of Florida, Inc. - Practitioner

Page 5 of 13

PRACTITIONER NAME:

Application

Modification to the wording or format of the Practitioner Application may invalidate the application.

13. BOARD CERTIFICATION

Does Not Apply

Are you board or otherwise professionally certified?

Yes If "Yes", please complete below:

Issuing Board/Entity and State Issued

No If "No", describe your intent for certification, if any, and dates of testing for

Certification on separate sheet.

Date

Expiration Date

Specialty

Date Certified

Recertified

(if any)

Have you applied for certification other than those indicated above?

Yes

No

If so, list certification and date: If you participate in a specialty which does not have board certification, please indicate specialty:

14. PROFESSIONAL AFFILIATIONS (Do not abbreviate)

Please List Membership In All Professional Societies Complete Name of Society:

Date Joined

/

/

.

/

/

.

Current Member

YES

NO

YES

NO

15. OTHER CERTIFICATIONS ACLS, BLS, ATLS, PALS, NALS (e.g., Fluoroscopy, Radiography, etc.)

(Attach Certificate if Applicable)

Type:

Number:

Expiration Date:

Type:

Number:

Expiration Date:

16. HOSPITAL, MILITARY, AND OTHER INSTITUTIONAL AFFILIATIONS

Does Not Apply

Please list in reverse chronological order (with the current affiliation(s) first) all institutions where you (A) have current

affiliations, (B) applications in process, (C) previous hospital affiliations, (D) current military affiliations, (E) previous military affiliations. (F) In-patient coverage plan (for those without admitting privileges). List only affiliations here, list employment

in section XVI, Work History.

A. CURRENT HOSPITAL AFFILIATIONS (Do not abbreviate) Name of Primary Admitting Hospital: Mailing Address Phone number: Status (active, provisional, courtesy, temporary, etc.): Can you admit / follow patients at this hospital? Yes No

Department: City, State , Zip Fax Number: Appointment Date:

Molina Healthcare of Florida, Inc. - Practitioner

Page 6 of 13

PRACTITIONER NAME:

Application

Modification to the wording or format of the Practitioner Application may invalidate the application.

Name of Secondary Admitting Hospital: Mailing Address Phone number: Status: Can you admit / follow patients at this hospital? Name of Other Institutions: Mailing Address Phone number: Status: Can you admit / follow patients at this hospital?

Yes No Yes No

Department: City, State, Zip Fax Number: Appointment Date:

Department: City, State, Zip Fax Number: Appointment Date:

B. HOSPITAL APPLICATIONS IN PROCESS (Do not abbreviate)

Hospital/Institution:

Phone Number/Fax Number:

Mailing Address:

City:

Hospital/Institution:

Phone Number/Fax Number:

Mailing Address:

City:

Date Application Submitted:

State:

Zip Code:

Date Application Submitted:

State:

Zip Code:

C. PREVIOUS HOSPITAL AFFILIATIONS (Do not abbreviate) Name of Admitting Hospital:

Department:

Mailing Address

City, State, Zip

Phone Number:

Previous Status (active, provisional, courtesy, temporary, etc.):

From (mm/yyyy):

Fax Number: To (mm/yyyy):

Reason for Leaving:

Name of Admitting Hospital:

Department:

Mailing Address

City, State, Zip

Phone Number:

Fax Number:

Previous Status (active, provisional, courtesy, temporary, etc.): Reason for Leaving:

From (mm/yyyy):

To (mm/yyyy):

Molina Healthcare of Florida, Inc. - Practitioner

Page 7 of 13

PRACTITIONER NAME:

Application

Modification to the wording or format of the Practitioner Application may invalidate the application.

D. CURRENT MILITARY AFFILIATIONS (Do not abbreviate) Name of Primary Base: Mailing Address Phone number: Status (active, provisional, courtesy, temporary, etc.):

E. PREVIOUS MILITARY AFFILIATIONS (Do not abbreviate) Name of Primary Base: Mailing Address Phone number: Status (active, provisional, courtesy, temporary, etc.):

Division City, State , Zip Fax Number: Appointment Date:

Division City, State , Zip Fax Number: Appointment Date:

17. Inpatient Coverage Plan (for those without admitting privileges)

Name of Admitting Physician/Practice/Clinic/Group:

Hospital Where privileged:

Does Not Apply

18. Covering Providers/Call Group

Provider Name & Degree

Specialty

Address

Does Not Apply Phone Number

Molina Healthcare of Florida, Inc. - Practitioner

Page 8 of 13

PRACTITIONER NAME:

Application

Modification to the wording or format of the Practitioner Application may invalidate the application.

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