The Mississippi Participating Physician Application form is a comprehensive document designed for physicians seeking to join a managed care entity in Mississippi, either for the first time or for reappointment. This essential form collects detailed information on practice, education, licensure, work history, and more, ensuring candidates meet the necessary criteria before affiliation. Physicians are urged to fill out the application with accuracy and include all required supporting documents, to streamline the evaluation process and facilitate their participation in the managed care system.
In today's healthcare landscape, the process of ensuring practitioners are properly vetted and credentialed is crucial for maintaining high standards of care. The Mississippi Participating Application form serves as a fundamental tool in this mission, aimed at physicians who seek to join or re-affirm their status within managed care entities. This detailed application mandates comprehensive information regarding the applying physician's practice, educational background, licensure, and work history, underscoring the importance of thoroughness and accuracy. Applicants are instructed to avoid abbreviations and to provide additional sheets if the space provided is insufficient, ensuring each response is clear and complete. The form requires current copies of essential documents such as medical licenses, DEA Certificates, and evidence of liability coverage, among others. Notably, it also gathers information on practice logistics, such as office locations, hours of operation, and emergency coverage arrangements, as well as on the diversity of services provided. Information on board certifications, participation in electronic data interchange, and affiliations with medical groups or networks is also solicited, painting a holistic picture of the applicant's professional profile. Acknowledging the diversity of applicants, the form includes sections for voluntary disclosure of race/ethnicity and the application of healthcare services to different patient demographics. For those involved in the management or ownership of healthcare-related organizations, disclosure is required, reflecting the form's comprehensive approach to understanding the applicant's professional environment. This meticulous documentation process not only facilitates the managed care entity's evaluation of candidates but also serves as a reflection of the healthcare industry's commitment to upholding rigorous standards of quality and accountability.
CONFIDENTIAL/PROPRIETARY
Please check one:
Mississippi Participating Physician
Original Application
Application
Reappointment
This application is submitted to:_______________________________, herein, this Managed Care Entity 1.
SECTION A.
Practice, Educational, Licensure and Work History Information
I. INSTRUCTIONS
This form should be typed or legibly printed in black ink. If more space is needed than provided on original, attach additional sheets and reference the questions being answered. Please do not use abbreviations when completing the application. If an item in the application does not apply to you, write N/A in the box provided. Current copies of the following documents must be submitted with this application.
z State Medical License(s)
z Face Sheet of Professional Liability Policy or Certification
z DEA Certificate
z Curriculum Vitae
z Board Certification (if applicable)
z ECFMG (if applicable)
II. IDENTIFYING INFORMATION
Last Name:
First:
Middle:
Is there any other name under which you have been known (AKA/Maiden Name)? Name(s):
Home Mailing Address:
City:
State:
ZIP:
Home Telephone Number:
E-Mail Address:
Home Fax Number:
Pager Number:
Birthday Date:
Birth Place (City/State/Country):
Citizenship (If not a United States citizen, please include a copy of
Alien Registration Card).
Social Security #:
Gender 2 :
Male
Female
Race/Ethnicity 2
Specialty:
(voluntary):
Subspecialties:
Internal Medicine
III. PRACTICE INFORMATION
Practice Name (if applicable):
Department Name (if Hospital based):
Primary Office Street Address:
Primary Office Mailing Address if different from Street Address:
County:
Zip:
Telephone Number:
FAX Number:
Office Manager/Administrator:
Fax Number:
Name Affiliated with Tax ID Number:
Federal Tax ID Number:
1As used in the information Release/Acknowledgements Section of this application, the term “this Managed Care Entity” shall refer to
the entity to which the application is submitted as identified above.
2 This information will be used for consumer information purposes only.
Mississippi Participating Physician Application – 11/99
Page 1 of 12
Secondary Office Street Address:
Tertiary Office Street Address:
(
)
Handicap Access:
24 Hour Coverage:
Yes
No
Will you accept new patients?
Back office Telephone Number:
Please identify other networks in which you participate:
Please identify other networks from which you have been denied admission or de-selected:
Name of Network
Address
Reason for Denial or Deselection
Do you have ownership in any health or medical related organization, e.g., laboratory, home health care agency, radiology facility,
lithotrips, mobile testing, MRI, etc?
If Yes, please list:
Medical Group(s) / IPA(s) Affiliation:
Do you intend to serve as a primary care provider?
Please check all that apply:
Do you intend to serve as a specialist?
Solo Practice
Single Specialty
If Yes, please list specialty(s):
Group Practice
Multi Specialty
Do you employ any allied health professionals (e.g. nurse practitioners, physician assistants, psychologists, etc.)?
If so, please list:
Name:
Type of Provider:
License Number:
______________________________________ _______________________________________________________________________
______________________________________ __________________________________________________ _____________________
______________________________________ ___________________________________________________ _____________________
Do you personally employ any physicians? (Do Not include physicians that are employed by the medical group)
Mississippi Medical License Number:
_________________________________________________________________
_____________________________________________
____________________________________________
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Please list any clinical services you perform that are not typically associated with your specialty:
Please list any clinical services you do not perform that are typically associated with your specialty:
Is your practice limited to certain ages?
If Yes, specify limitations:
NO
Do you participate in EDI (electronic date interchange)?
Do you use a practice management system/software: Yes
If so, which Network?
If so, which one?
What type of anesthesia do you provide in your group/office?
Local
Regional
Conscious Sedation
General
None
Other (please specify):
___________________
Has your office received any of the following accreditation’s, certifications, or licensures?
American Association for Accreditation of Ambulatory Surgery Facilities (AAASF)
Medicare Certification
Mississippi Department of Health Licensure
Other:
IV. BILLING INFORMATION
Billing Company:
Street Address:
Contact:
V. OFFICE HOURS – Please indicate the hours your office is open:
Monday
Tuesday
Wednesday
Thursday
Friday
24 HOUR
COVERAGE
Saturday
24HOUR COVERAGE
Sunday
Holidays
VI. COVERAGE OF PRACTICE (List your answering service and covering physicians by name. Attach additional sheets if necessary. Reference this section number and title)
Answering Service Company:
Telephone Number: ( )
Fax Number: ( )
Mailing Address:
Covering Physician’s Name:
If you do not have hospital privileges, please provide written plan for continuity of care:
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VII. FOREIGN LANGUAGES SPOKEN
Fluently by Physician:
Fluently by Staff:
VIII. LABORATORY SERVICES
If you provide direct laboratory services, please indicate the TIN utilized and provide Clinical Laboratory Information Act (CLIA) information. Attach a copy of your CLIA certificate or waiver if you have one.
Tax ID #:
Billing Name:
Type of Service Provided:
Do you have a CLIA Certificate?
Do you have a CLIA waiver?
Certificate Number:
Certificate Expiration Date:
IX. MEDICAL/PROFESSIONAL EDUCATION
(Attach additional sheets if necessary. Reference this
section number and title.)
Medical School:
Degree Received:
Date of Graduation (mm/yy)
State & Country:
Medical/Professional School:
State & Country
X.
INTERNSHIP/PGYI (Attach additional sheets if necessary, Reference this section number and title.)
Institution:
Program Director:
Type of Internship:
From: (mm/yy)
To: (mm/yy)
XI.
RESIDENCES/FELLOWSHIPS (Attach additional sheets if necessary. Reference this section
number and title.)
Include residencies, fellowships, preceptorships, teaching appointments (indicate whether clinical or academic). And postgraduate education in chronological order, giving name, address, city, state, country, zip code and dates. Include all programs you attended, whether or not completed.
Type of Training (e.g. residency, etc)
Did you successfully complete the program?
No (If “No”, please explain on separate sheet.)
Page 4 of 12
(If “No”, please explain on separate sheet.)
XII. BOARD CERTIFICATION (Attach copies of documents.)
Include certifications by board(s) which are duly organized and recognized by: z a member board of the American Board of Medical Specialties
z a member board of the American Osteopathic Association
z a board or association with an Accreditation Council for Graduate Medical Education of American Osteopathic Association approved post graduate training that provides complete training in that specialty or subspecialty.
Name of Issuing Board:
Certification Number:
Date Certified/ Rectified:
Expiration Date (if any):
Have you applied for board certification other than those indicated above?
Yes No
If so, list board(s) and date(s):
If not certified, describe your intent for certification, if any, and date of admissibility for certification on separate sheet.
Have you taken or failed a board exam?
If Yes, Provide details.
XIII. OTHER CERTIFICATIONS (e.g. Fluoroscopy, Radiography, etc.) (Attach additional sheets if necessary.
Reference this section number and title.)
Type:
Number:
Expiration Date:
XIV. MEDICAL LICENSURE/REGISTRATIONS (Attach copies of documents)
Mississippi State Medical License Number:
Issue Date:
Active:
Drug Enforcement Administration (DEA) Registration Number:
Unlimited?
No If “No”, please explain on separate sheet
Controlled Dangerous Substances Certificate (CDS) (if applicable):
Page 5 of 12
ECFMG Number (applicable to foreign medical graduates):
Visa Number:
Date Issued:
Valid Through:
Medicare UPIN/National Physician Identifier (NPI):
Mississippi Medicare Number:
Mississippi Medicaid Number:
XV. ALL OTHER STATE MEDICAL LICENSES – List all Medical licenses now or Previously Held. (Attach additional sheets if necessary. Reference this section number and title.)
State
XVI. PROFESSIONAL ORGANIZATIONS
Please list county, state or national medical societies, or other professional organizations or societies of which you are a member or applicant.
ORGANIZATION NAME
Applicant
Member
Are you an Officer or Director of any of the professional organizations listed above?
XVII. PROFESSIONAL LIABILITY (Attach copy of professional liability policy or certification face sheet.)
Current Insurance Carrier:
Policy Number:
Original effective date:
( )
Per Claim Amount: $
Aggregate Amount: $
Please explain any surcharges to your professional liability coverage on a separate sheet. Reference this section number and title.
If you have had professional liability carriers in the last five years other than the one listed above, please list them below.
Name of Carrier:
Policy # :
State and Country::
State and Country:
Page 6 of 12
XVII. CURRENT HOSPITAL AND OTHER INSTITUTIONAL AFFILIATIONS
Please list in (A) in reverse chronological order, with the most current affiliation(s) first, all institutions with which you are currently affiliated. List previous affiliations during the past ten years in (B). Include hospitals, surgery centers, institutions, corporations, military assignments, or government agencies.
A. CURRENT AFFILIATIONS (Attach additional sheets if necessary. Reference this section number and title.)
Name and Mailing Address of Primary Admitting Hospital:
Department/Status (Active, provisional, courtesy, etc.):
Appointment Date:
Name and Mailing Address of Other Hospital/Institution:
Department/Status (Active, provisional, courtesy, etc)
If you do not have hospital privileges, please explain.
B. PREVIOUS AFFILIATIONS (Limit to last ten years. Attach additional sheets if necessary. Reference this section number and title.)
Reason for Leaving:
Name and Mailing Address of other Hospital/institution:
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XIX. PEER REFERENCES
List three professional references, preferably from your specialty area. Do not list relatives, current partners or associates in practice. If possible, include at least one member from the Medical Staff of each facility at which you have privileges. Do not include program directors previously listed under post graduate training and education in Section X.
NOTE: References must be from individuals who are directly familiar with your work, either via direct clinical observation or through a close working relationship.
Name of Reference:
XX. WORK HISTORY (Attach additional sheets if necessary. Reference this section number and title.)
Chronologically list all work history for at least the past five years (use extra sheets if necessary). This information must be complete. A curriculum vitae is sufficient provided it is current and contains all information requested below. Please explain any gaps in professional work history on a separate page.
Current Practice:
Contact Name:
Name of Practice/Employer:
Page 8 of 12
Section B.
Professional Liability Action Explanation
Please complete this section for each pending, settled, or otherwise concluded professional liability lawsuit or arbitration filed and served against you, in which you were named a party in the past five (5) years, whether the lawsuit or arbitration is pending, settled or otherwise concluded, and whether or not any payment was made on your behalf by any insurer, company, hospital, or other entity. All questions must be answered completely in order to avoid delay in expediting your application. If there is more than one professional liability lawsuit or arbitration action, please photocopy this Section B prior to completing, and complete a separate form for each lawsuit.
I. CASE INFORMATION
City, County and State where lawsuit filed:
Court case number, if known:
Date of alleged incident serving as basis for the lawsuit/arbitration:
Date Suit Filed:
Sex of patient:
Age of patient:
Location of Incident:
Hospital
My office
Other doctor’s office
Surgery Center
Other, (please specify)
__________________________________________________________________________________
Your relationship to Patient (Attending Physician, Surgeon, Assistant, Consulting, etc.):
Allegation:
Is/was there any insurance company or other liability protection company or organization providing coverage/defense of the lawsuit or
arbitration action?
If Yes, please provide company name, contact person, phone number, location and claim identification number of insurance company or other liability protection company or organization.
_________________________________________________________________________________________________________________
If you would like us to contact your attorney regarding any of the above, please provide attorney(s) name(s) and phone number(s). Please fax this document to your attorney to serve as your authorization:
Name: ____________________________________________________ Phone Number: _________________________________
Name: ____________________________________________________ Phone Number: __________________________________
II. WHAT IS THE STATUS OF THE LAWSUIT/ARBITRATION DESCRIBED ABOVE? (CIRCLE ONE)
Lawsuit/arbitration still ongoing, unresolved.
Judgement rendered and payment was made on my behalf.
Amount paid on my behalf:
_______________________
Judgement rendered and I was found not liable.
Lawsuit/arbitration settled and payment made on my behalf.
________________________
Lawsuit/arbitration settled, no judgement rendered, no payment made on my behalf.
Summarize the circumstances giving rise to the action. If the action involves patient care, provide a narrative, with adequate clinical detail, including your description of your care and treatment of the patient. If more space is needed, attach additional sheet(s). Include: (1) condition and diagnosis at time of incident. (2) dates and description of treatment rendered, and (3) condition of patient subsequent to treatment. Please print.
Page 9 of 12
SUMMARY
SECTION C.
Certification
I certify that the information in Section A and B of this application and any attached documents (including my curriculum-vitae if attached) is true, current, correct and complete to the best of my knowledge and belief and is furnished in good faith. I understand that intentionally withholding or omitting material information or intentionally submitting material false or misleading information may result in denial of my application or termination of my privileges, employment or physician participation agreement. I agree that the Managed Care Entity to which this application is submitted, its representatives, and any individuals or entities providing information to this Managed Care Entity in good faith shall not be liable, to the fullest extent provided by law, for any act or occasion related to the evaluation or verification contained in this Mississippi Participating Physician Application. In order for participating Managed Care Entities or Healthcare Organizations to evaluate my application for participation in and/or my continued participation in those organizations, I hereby give permission to release to this Managed Care Entity information about my medical malpractice insurance coverage and malpractice claims history. This authorization is expressly contingent upon my understanding that the information provided will be maintained in a confidential manner and will be shared only in the context of legitimate credentialing and peer review activities. This authorization is valid unless and until it is revoked by me in writing. I authorize the attorneys listed in Section B, Page 9, to discuss any information regarding the subject case with this Managed Care Entity.
Print Name Here: ___________________________________________________________________________
Physician Signature: ____________________________________________________________ Date: __________________________
(Stamped Signature Is not Acceptable)
Page 10 of 12
Filling out the Mississippi Participating Application form is a significant step for healthcare providers looking to affiliate with a Managed Care Entity in Mississippi. This process involves providing detailed information about practice history, education, licensure, and additional credentials. It's vital to approach this task with precision to ensure that all the provided information is accurate and complete. Once the form is submitted, it will undergo a thorough review process. The reviewing entity will assess the applicant's qualifications and decide on their eligibility to participate in the network. During this time, applicants may need to provide additional information or clarification.
After submission, it is advisable to follow up with the Managed Care Entity to confirm receipt of your application. Ensure you remain available for any inquiries or requests for additional information. This proactive approach can facilitate a smoother review process.
What documents are required to accompany the Mississippi Participating Physician Application?
To ensure a comprehensive submission, you should include current copies of the following documents with your Mississippi Participating Physician Application: your State Medical License(s), the Face Sheet of your Professional Liability Policy or Certification, your DEA Certificate, Curriculum Vitae, Board Certification (if applicable), and the ECFMG certification (if applicable). It’s vital that these documents are up to date to avoid any processing delays.
How should additional information be presented if the space provided in the application is insufficient?
If you find that the space on the form is not sufficient for your answers, you are encouraged to attach additional sheets. However, it's important to reference the questions you're answering on these additional pages. Make sure any extension of your responses is clearly tied back to the respective question on the original form to ensure clarity and avoid any confusion during the review process.
Is it necessary to avoid abbreviations in the application, and what should I do if a question does not apply to me?
Yes, it is crucial to avoid using abbreviations when completing the application. The aim is to provide clear and easily understandable information. In instances where a question does not apply to you, you should write "N/A" in the provided box. This helps to affirm that you have acknowledged and considered the question, but it is not relevant to your situation.
How is personal information such as gender, race/ethnicity, and citizenship addressed in the application process?
Information regarding gender, race/ethnicity, and citizenship is collected solely for consumer information purposes. As such, you are requested to provide your Social Security number, and, if you are not a citizen of the United States, a copy of your Alien Registration Card. This information assists in ensuring that the needs of diverse populations are considered and met effectively.
What should I do if I have multiple office locations or practice affiliations?
For physicians with multiple office locations or practice affiliations, the application provides spaces to input details for primary, secondary, and tertiary offices. You should include information such as the office street and mailing address, office manager or administrator's contact details, and the Federal Tax ID Number associated with each location. This comprehensive approach allows for a thorough understanding of your practice's framework and reach.
What is the protocol if I do not have hospital privileges?
If you do not have hospital privileges, it is required that you provide a written plan for the continuity of care. This plan should outline how you intend to ensure patients receive the necessary hospital care when needed, despite the lack of direct hospital affiliations. The goal here is to maintain a high standard of patient care and safety, even in the absence of direct privileges.
When filling out the Mississippi Participating Application form, there are common mistakes that applicants should diligently avoid to ensure their application process is smooth and successful. These errors can delay the application process or impact the applicant's eligibility for participation. Being attentive and thorough when completing the form can make a significant difference in the outcome. Here are nine common mistakes:
Not following instructions on the form, such as failing to type or legibly print in black ink, which can lead to processing delays if the form is difficult to read.
Using abbreviations instead of writing out full names and terms as requested, which can cause confusion and inaccuracies in the recorded information.
Omitting to attach additional sheets when more space is needed, potentially leaving important questions unanswered or information incomplete.
Incorrectly handling the section that requires stating 'N/A' for items that do not apply, leading to the possibility of appearing to have ignored certain questions.
Forgetting to include current copies of required documents such as State Medical License(s), DEA Certificate, or Professional Liability Policy, which are essential for the verification process.
Failing to provide complete identifying information, including any other names previously used, which is critical for a thorough background check.
Neglecting to accurately disclose practice information, which is necessary for assessing the applicant's suitability and for proper contact and billing purposes.
Inaccurately indicating office hours or coverage which could lead to administrative misunderstandings regarding the physician's availability.
Not being clear about the types of clinical services provided or excluded from their practice, potentially leading to misrepresentations of their capabilities.
This list is not exhaustive but represents critical areas where attention to detail can prevent unnecessary complications. Ensuring accuracy and completeness when filling out forms like the Mississippi Participating Application is a foundational step towards a successful and professional relationship with the Managed Care Entity.
When it comes to the documentation required for the Mississippi Participating Physician Application, the process involves multiple steps and a variety of significant paperwork. Applicants are obligated to furnish a comprehensive set of documents to support their application. These documents attest to their qualifications, professional background, and compliance with the necessary legal and regulatory standards. This narrative elucidates a collection of documents commonly submitted alongside the Mississippi Participating Application form, each serving its unique purpose in the broader context of application completion.
The aforesaid documents collectively contribute to a portfolio that underscores the applicant's eligibility, expertise, and commitment to high standards of medical practice. It is incumbent upon the applicant to ensure the accuracy and completion of these documents as they navigate the application process, thus facilitating a seamless review by the relevant managed care entity. While the list is comprehensive, applicants should verify specific requirements, as additional documents may be necessary depending on individual circumstances or changes in regulatory demands.
The Mississippi Participating Physician Application form shares similarities with the Credentialing Application often required by hospitals or medical groups. Both forms serve as a thorough vetting process for healthcare providers before they are allowed to join a particular medical facility or network. Each document requests detailed information about the applicant's education, training, licensure, work history, and any certifications held. This ensures that only qualified and competent healthcare professionals are considered for affiliation, thereby upholding the standards of care and patient safety within the institution.
Similarly, the form aligns with the structure and purpose of Medical Staff Privileges Applications used by hospitals. These applications are crucial for determining which physicians are given the authority to provide care within the hospital setting. They delve into the practitioner’s background, including work history, specialties, board certifications, as well as any disciplinary actions or malpractice claims. By evaluating such criteria, hospitals can maintain a high-quality medical staff and minimize risks to patient safety.
Another counterpart is the Provider Enrollment Form for health insurance plans, including Medicare and Medicaid. These forms are requisite for physicians and other healthcare providers who intend to become part of an insurance network. Like the Mississippi Participating Physician Application, they gather extensive professional details to ensure the provider meets the specific standards and regulations set forth by the insurance entity. This scrutiny helps in fostering a reliable, quality network of providers that insurance plan members can trust for their healthcare needs.
Lastly, the National Provider Identifier (NPI) Application can also be likened to the Mississippi form. The NPI is a unique identification number required for all healthcare providers in the United States, as mandated by HIPAA. While the primary purpose is to assign this identifier, the application process similarly collects comprehensive information about the healthcare provider's qualifications, practice locations, and specialties. This nationwide system enhances the efficiency of electronic transmission of health information and assists in the accurate tracking of healthcare providers.
Filling out the Mississippi Participating Application form is a critical step for physicians aiming to participate in managed care within the state. The process involves providing detailed practice, educational, licensure, and work history information. Paying attention to the application's requirements can streamline the review process and help avoid potential delays in participation approval. Below are essential dos and don'ts when completing this form:
By following these guidelines, applicants can ensure their submission is complete and stands the best chance of being processed efficiently. Remember, the quality and accuracy of your application reflect your professionalism and attention to detail, attributes highly valued in the medical profession.
Many misconceptions surround the Mississippi Participating Application form, affecting physicians and healthcare providers. Addressing these common misunderstandings can help ensure the process is accurately navigated.
Understanding these misconceptions and accurately completing the Mississippi Participating Application form is crucial for physicians and healthcare providers looking to be part of Managed Care Entities in Mississippi.
When completing the Mississippi Participating Application form, there are several key points that applicants must keep in mind to ensure the process is completed accurately and efficiently. These takeaways are crucial for any physician seeking to apply or reapply for participation with a Managed Care Entity in Mississippi.
Adhering to these key takeaways during the application process can help ensure that a physician's information is presented clearly and completely, reducing the likelihood of delays or complications in joining or reapplying to a Managed Care Entity in Mississippi.
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