The North Carolina Department of Insurance Uniform Application is a standardized form designed for health care practitioners seeking to participate in health benefit plans. This application, mandated by North Carolina General Statute 58-3-230, ensures that insurers use a consistent process for credentialing providers within their networks. It is essential for applicants to complete all required sections accurately and submit the form directly to the organizations they wish to contract with.
The North Carolina Department of Insurance Uniform Application to Participate as a Health Care Practitioner is a crucial document for healthcare providers seeking to join insurance networks. This application, mandated by North Carolina General Statute 58-3-230, ensures that insurers credentialing providers adhere to standardized requirements. It is important to note that insurers cannot request additional information beyond what is specified in the form. The application process includes several key components, such as providing personal and demographic data, details about the practice, and documentation of qualifications. Applicants must ensure that all sections are completed, marking any non-applicable questions with "N/A." Additionally, various supporting documents must be included, such as copies of state licenses, DEA certificates, proof of professional liability insurance, and letters of reference. These elements work together to verify the provider’s credentials and readiness to deliver care. The application requires careful attention to detail, as only the Commissioner of Insurance can authorize changes to the form, emphasizing the importance of accuracy in the submission process. By following the outlined instructions, healthcare practitioners can navigate the application smoothly, paving the way for their participation in health benefit plans.
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North Carolina Department of Insurance
Uniform Application
To Participate as a Health
Care Practitioner
Note: Please send completed applications directly to the
organizations with which you seek to contract.
The following application is a form approved by the North Carolina Department of Insurance, in accordance with North Carolina General Statute 58-3-230. Every insurer that provides a health benefit plan and credentials providers for its network is required to use this form and the insurer may not require an applicant to submit information that is not required by this form Only the Commissioner of Insurance is authorized to make changes, deletions or additions to this form.
June 2005
Page 1
INSTRUCTIONS
Before submitting the Application, make sure you have completed the following: Include an answer in all spaces. Indicate "N/A", if the question is not applicable. The provider has signed and dated the last page of the Application.
Before submitting the Application, make sure you have enclosed the following, if applicable: Copy of the provider's original state(s) license(s) and current registration.
Copy of current DEA certificate. (Must have a valid date and refer to current address.) Copy of South Carolina Controlled Drug Substance Certificate and DEA information.
Copy of the face sheet of your current professional liability insurance policy, indicating by name, provider(s) covered, coverage amounts, effective date, expiration date, and policy number. Attach previous carrier face sheet.
Proof of professional liability insurance for non-physician providers who care for patients in your practice. Copy of certificate from the Specialty Board.
Copy of Educational Commission of Foreign Medical Graduate Certificate- ECFMG. Letter(s) of reference, recommendation, and/or oversight, if required.
Copy of Curriculum Vitae or work history after graduation from Medical, Dental or other professional school
(CV must account for any gaps of 90 days or more).
Copy of CLIA (Clinical Laboratory Improvement Amendments) /ACR (American College of Radiology). Copy of W-9 Form.
Examples of documentation to attach to this application:
Page 2
A.DEMOGRAPHIC AND PERSONAL DATA:
1.
2.
3.
4.
5.
Name of Applicant:
(Last Name)
(First Name)
(Middle Name)
(Maiden)
Date of Birth:
Place of Birth:
Social Security Number:
Sex:
Male
Female
Type of Practice:
Primary Care:
Specialist:
(Primary Specialty)
(Secondary Specialty)
Please Identify Areas of Clinical Expertise:
What population(s) do you treat (e.g. geriatric, all ages):
Name of Practice:
Primary Office Address (If you maintain more than one office, list each office, address, and hours of operation)
Practice Name:
Address:
(Street)(City)(County) (State) (Zip)
Handicapped Accessible?
YES
NO
Office Phone:
Fax:
E-mail address:
Accepting New Patients?
Restrictions:
(Please list or indicate none)
Office Hours:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Secondary Office Address
Page 3
A. DEMOGRAPHIC AND PERSONAL DATA (Continued)
Additional Office Address or Billing Address, if different (check one)
Billing
Office
Name:
Office Phone: xxx-xxx-xxxx/xxxx
Fax: xxx-xxx-xxxx/xxxx
6.Name other provider(s) in your practice (if not enough space, please attach additional sheet):
7.Do nurse practitioners, physician assistants, midwives, social workers, or other non-physician providers provide care to
patients in your practice?
(If yes, please attach proof of professional liability insurance and proof of employment for those individuals)
8.
Name and address of provider(s) who share call with you (if not enough space, please attach additional sheet):
9.
10.
Arrangements for 24 hour/7 day coverage:
Administrative Contact:
(Title)
xxx-xxx-xxx/xxxx
(Name)
(Telephone)
11.IRS requires reimbursement be made payable to name of practice affiliated with Federal Tax ID Number:
Federal Tax ID Number:
Name (if different from practice name):
Billing Address (if different from practice address):
12.
13.
UPIN Number:
Medicare/Medicaid Number:
/
National Provider Identifier (NPI):
DEA Number:
Exp. Date:
(Attach copy to application)
Page 4
A.DEMOGRAPHIC AND PERSONAL DATA (Continued)
COMPLETE ONLY IF LICENSED IN SOUTH CAROLINA
SC Controlled Drug Substance Certificate:
Expiration Date:
(Attach a copy to application)
14.
Provide the following information for each state in which you are currently or were previously licensed to Practice (If not enough space please attach additional sheet)
STATE
DATE OF LICENSE
LICENSE NUMBER
STATUS
EXPIRATION
Active, Inactive, Suspended
DATE
PLEASE ATTACH A COPY OF EACH STATE LICENSE CERTIFICATE
15.
Certification of Specialty Boards as applicable:
a.If you are certified by a specialty board, indicate name of board and date of certificate.
Date Certified:
(Primary Specialty Board)
(Secondary Specialty Board)
b..
Are you listed in the American Board of Medical specialists? YES
c.If you have applied to a specialty board for examination, give the name of board and the date of scheduled examination. Date:
d. If you have not applied to a specialty board, please explain:
Page 5
16.
List the dates of all current professional memberships in societies, including state and county societies:
FROMTO
17.
List all hospitals where you currently have privileges and indicate the type and status of those privileges:
(Type: active, admitting, associate, consulting, courtesy.
Status: pending, provisional, suspended, temporary, visiting)
Hospital
Privilege and Status of Privilege
Estimated % of Admission
(primary admitting facility)
18.
If you do not have admitting privileges, who admits for you?
Name:Name:
Address:Address:
Phone:
Page 6
B.EDUCATION AND PRACTICE HISTORY
Medical, Dental, or other Professional School Attended:
Institution:
(Street)
(City)
(State)
(Zip)
Degree:
From:
To:
Please attach Educational Commission of Foreign Medical Graduate Certificate – (ECFMG), if applicable.
Internship
Specialty:
From: xx/xx/xxxx
xx/xx/xxxx
Residency
Other Residency / Fellowship – (specify)
Page 7
B. EDUCATION AND PRACTICE HISTORY (Continued)
6.
7.
List work history since beginning of medical, dental, or other professional school; please be specific.
(If not enough space, please attach additional sheet)
(Current Practice)
(Previous Practice)
List other training and/or education (including CME) within the last three years, if applicable.
Have you involuntarily or voluntarily withdrawn or been suspended from any internship, residency or fellowship training program? Please explain:
Please explain any incident(s) in which you have involuntarily or voluntarily withdrawn your application for appointment, clinical privileges or reappointment before a decision was made by a hospital or healthcare facility’s governing board.
Page 8
C.PROFESSIONAL INFORMATION
Please check yes or no for the following questions. Please complete the attached Supplemental Form for any questions to which you answer “yes”. Also please sign and date this application. If this application does not have the provider’s signature, it cannot be accepted.
Has your license to practice in any jurisdiction ever been limited, restricted, reduced, suspended,
Y
N
voluntarily surrendered, revoked, denied or not renewed; have you ever been reprimanded by a state
licensing agency; or are any of these actions pending with respect to your license; are you under
investigation by any licensing or regulatory agency? (If yes, please complete Supplemental Question
No. 1.)
Has your professional employment or membership in a professional organization ever been subject
to disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed,
or voluntarily relinquished during or under threat of termination for any reason? (If yes, please
complete Supplemental Question No.2.)
Has your Drug Enforcement Agency registration or other controlled substance authorization ever
been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily
surrendered or limited your registration during or under the threat of an investigation or are any
such actions pending? (If yes, please complete Supplemental Question No.3.)
Have you ever been sanctioned or suspended by Medicare or Medicaid? (If yes, please complete
Supplemental Question No.4.)
To your knowledge, have you ever been reported to the National Practitioner Data Bank or the
North/South
Carolina Board of Medical Examiners? (If yes, please complete Supplemental Question No.5.)
Have you ever been convicted of a felony or misdemeanor, or are you under investigation with
respect to such conduct? (If yes, please complete Supplemental Question No.6.)
Has a professional liability claim been assessed against you in the past five years, or are there any
professional liability cases pending against you? (If yes, please complete Supplemental Question
No.7.)
Has any liability insurance carrier canceled, refused coverage, or rated up because of unusual risk or
have any procedures been excluded from your coverage? (If yes, please complete Supplemental
Question No. 8.)
Have you ever practiced without liability coverage? (If yes, please complete Supplemental Question
No.9.)
Do you currently have any medical, chemical dependency or psychiatric conditions that might
adversely affect your ability to practice medicine or surgery or to perform the essential functions of
your position? (If yes, please complete Supplemental Question No.10.)
11.
Have your Hospital and/or Clinic privileges ever been limited, restricted, reduced, suspended,
revoked, denied, not renewed, or have you voluntarily surrendered or limited your privileges during
or under the threat of an investigation or are any such actions pending? (If yes, please complete
Supplemental Question No. 11).
Page 9
SUPPLEMENTAL FORM
Provider Name:
Provider ID#
(if applicable)
1. License Limited, Reprimanded, etc.
List State(s) where action took place:
Date(s) License revoked, suspended, etc.
From xx/xx/xxxx
To xx/xx/xxxx
Please explain:
2. Employment/Membership Suspended, Limited, etc.
List Professional Organization:
3. Drug Enforcement Agency (DEA) Explanation.
Page 10
1. Complete All Sections: Ensure that every section of the application is filled out. If a question does not apply to you, write "N/A" in that space. This helps prevent delays in processing your application.
2. Gather Required Documentation: Before submitting your application, collect all necessary documents. This includes copies of your licenses, current DEA certificate, proof of insurance, and any other required certifications. Missing documents can lead to rejection.
3. Sign and Date: Don’t forget to sign and date the last page of the application. An unsigned application may be considered incomplete and could be returned.
4. Submit to the Correct Organization: After completing the application, send it directly to the organization with which you want to contract. This ensures that your application reaches the right place for consideration.