Hoosier Healthwise Healthy Indiana Plan Hospital/ancillary - Mdwise
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2HOOSIER HEALTHWISE HEALTHY INDIANA PLAN
HOSPITAL/ANCILLARY CREDENTIALING/ENROLLMENT FORM
Please select the program(s) for which this form applies:
q Healthy Indiana Plan (HIP)
q Hoosier Healthwise (HHW)
APPLICATION INSTRUCTIONS In order to be considered complete:
1. All information must be legible (please print or type)
2. Application must be completed in its entirety
3. Application must be signed and dated
4. Use a separate sheet of paper to provide additional information, if necessary
5. Current copies of all documents applicable to your organization MUST be submitted with this application:
• State License
• Copy of Medicaid certification letter
• CMS site evaluation - if state site survey is not available
• Liability coverage Face sheet
• Indiana Department of Health Accreditation Certificate with site survey
• TIN W-9
• Copy of Medicare certification letter
• CLIA
• DEA
DEMOGRAPHIC INFORMATION
Entity Name
Medicaid Number
DBA Name or Legal Name
Indiana State License No.
Fed. Tax ID Number
NPI
Taxonomy Number
Medicare Number
Address
City, St., ZIP
County
Contact Name
Contact Title
Accreditation Type:
q Joint Commission of Accreditation of Healthcare Organizations (JCAHO)
q National Commission of Quality Assurance (NCQA)
q Health Care Finance Administration (HCFA)
q Indiana State Department of Health (ISDH)
q Other ___________________________________________________________
BILLING INFORMATION
(if different from above)
Pay to:
Street
City, St., ZIP
Phone
Contact Person
Fax
COMPREHENSIVE/GENERAL/PROFESSIONAL LIABILITY
Liability Carrier
Coverage Limits
Policy Number
Expiration Date
ATTESTATION QUESTIONS
Please answer the following questions YES or NO. If YES, please provide full details on a separate sheet.
A. Has your organization’s malpractice insurance ever been terminated or revoked except with your consent or request?
q YES
q NO
B. Is your organization currently or has been in the last five years under investigation by any government entity or peer review?
q YES
q NO
C. Has your organization been sanctioned by Medicaid or Medicare?
q YES
q NO
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