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credentialing InTake Form

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Source

Clinic/Business Name: * Required

W-9 Name as listed on taxes: * Required

Business Address: * Required

Street Address City State / Province / Region ZIP / Postal Code Country

Phone: * Required

Fax: * Required

Email: * Required

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Date

MM slash DD slash YYYY

Business Website:

Organizational Tax ID#

Effective Date:

MM slash DD slash YYYY

Office Hours:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Do you provide phone coverage 24/7 days a week:

What source do you use:

Name: * Required

First Last

Phone: * Required

Email: * Required

Name of contact: * Required

First Last

Phone: * Required

Fax:

Billing address: * Required

Street Address City State / Province / Region ZIP / Postal Code Country

Make insurance and patient payments payable to:

Do you offer EFT (Electronic Funds Transfer) for insurance payments?

What types of patient payments do you accept: (Please select all applicable options) * Required

Cash

Check

Visa

Master Card

Discover

American Express

Other

Type of patient payments do you accept:

Medicaid #

L&I #

Medicare Part A PTAN#

Medicare Part B PTAN#

Name of Hospital or Facility utilized for admitting:

Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Phone: * Required

Fax:

Who is authorized to admit:

If skilled nursing facilities are utilized:

Yes

No

Name: * Required

Please add name of the skilled nursing facility.

Phone: * Required

Please add phone number of the skilled nursing facility.

Address: * Required

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please add address of the skilled nursing facility.

Are there any unique circumstances concerning your practice locations or the method by which you render health care services? (e.g. you only render services in patient's homes.)

Do you have interpreters at this location?

Yes

No

Do any employees speak a language other than English?

Yes

No

What language?

Is this location accessible by public transportation? (please circle).

Bus

Train

Is this location handicapped accessible?

Yes

No

Please explain what makes it handicapped accessible:

Do you have gender limitations?

Yes

No

Please explain:

Do you have age limitations?

Yes

No

Please explain:

Any other limitations?

Do you have any covering colleagues who are NOT partners or associates at any of your practice locations?

Yes

No

Names: * Required

Please provide names of these partners.

Addresses: * Required

Please provide addresses of these partners.

Is anesthesia administered in your office?

Yes

No

What category is used:

Administered by:

Do you offer Laboratory services on site?

Yes

No

Accrediting/certificating program:

Certification number:

Do you offer Radiology Services on site?

Yes

No

X-ray certification type:

Certification number:

Procedures: (Please select any of the following tests that may apply to this organization.)

EKG

Minor care of lacerations

Pulmonary function testing

Allergy injections

Allergy skin testing

Gynecology

PCP and OB

OB in practice

Deliveries

Blood draws

Asthma treatment

Age appropriate immunizations

Flexible sigmoidoscopy

Tympanometry / Audiometry screening

IV Hydration treatment

Osteopathic manipulation

Cardiac stress test

Physical therapy

Please indicate which insurance panels you are ALREADY contracted with:

Please indicate which NEW insurance panels you want HPMA to credential with:

3 + 6 = (for authentication purpose) * Required

Please enter a number that represents 3 + 6

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Address:

1010 Monroe Street
Bellingham, WA 98225

Phone:

(877) 733-9655

FAX:

(360) 733-9654

Email:

info@hopepma.com

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