Hoosier Healthwise Healthy Indiana Plan Hospital/ancillary

HOOSIER HEALTHWISE MANAGED CARE ORGANIZATION

HOSPITAL/ANCILLARY CREDENTIALING/ENROLLMENT FORM –

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Indiana Health Coverage Program Managed Care Organization and or Care Management Organization (IHCP MCO/CMO)

ATTESTATION AND AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize the Indiana Health Coverage Program Managed Care Organization and/or Care Management Organization

(IHCP MCO/CMO), its representatives, agents or designees, to obtain from any source, information and/or documents regarding

our entity’s qualifications related to this application for new or continued network provider privileges (herein after referred to

as “Credentialing Information”). We understand and agree that acceptance of this application does not constitute approval

or acceptance of participating provider status for any IHCP MCO contracted network, and grants no rights or privileges of

participation until such time as we receive actual written notice of acceptance and participating provider status. Termination

of this request for application is not an adverse action within the reporting requirements of the Healthcare Integrity and

Protection Data Bank and does not entitle us to any appeal or hearing. We understand that the IHCP MCO/CMO will conduct

an independent verification of this Credentialing Information and such information will be used to evaluate our credentials

according to the IHCP MCO/CMO standards. I hereby consent to the release of Credentialing Information to the IHCP MCO/

CMO, its agents, representatives or designees. This authorization to release Credentialing Information shall include, but not

be limited to, all Healthcare Integrity and Protection Data Bank and information from state regulatory and licensing agencies,

professional societies, accrediting agencies, and any companies from which we have obtained professional liability insurance.

We hereby release all third party sources of Credentialing Information from any and all liability related to the release of

such information that is provided in good faith and without malice. We hereby release and hold harmless from any and all

liability all members of the IHCP MCO/CMO, the Board of Directors, IT officers, agents, peer review committee members

and employees, for all activities regarding the evaluation of my credentials and qualifications or the denial or termination

of participating provider status in any IHCP MCO/CMO contracted network or the IHCP MCO/CMO. A photocopy of this

authorization will serve as an original. We understand that the IHCP MCO/CMO, the Credentialing Committee and/or their

designees will utilize this information only in connection with my application for credentialing or re-credentialing purposes. We

understand the IHCP MCO/CMO, its Credentialing Committee and their designees will treat this information as confidential.

The undersigned certifies and attests that the forgoing is truthful, correct and complete in all respects, and the undersigned

further understands the intentional submission of false or misleading information or the withholding of relevant information

is grounds for denial or immediate termination from the IHCP MCO/CMO provider networks. The undersigned hereby

agrees to report to IHCP MCO/CMO any changes in the above information within thirty (30) days of change. During the

credentialing and re-credentialing process, the IHCP MCO/CMO will obtain information from various outside sources

(e.g., state licensing agencies, Healthcare Integrity and Protection Database) to evaluate your application. You have

the right to review any primary source information that the IHCP MCO/CMO collects during this process. These rights do

not include information obtained as references, recommendations or other information that is peer review protected.

Printed Name ___________________________________________________________ Title ___________________________________________________________

Signature _______________________________________________________________ Date ___________________________________________________________

Should you believe any of the information used in the credentialing and re-credentialing process to be erroneous, or should any

information gathered as part of the primary source verification process differ from that submitted by you, as the practitioner, you

will have the right to correct any information and submit your comments and explanations for any other factual information.

Please keep a copy for your records.

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