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ORGANIZATIONAL PROVIDER APPLICATION

All fields are required. If information is not applicable to service type, please indicate by entering “N/A”. Applications submitted with blank fields will be returned to facility for completion.

DHS Approved HCBS Services Provided (Select all that apply)

Contracting Contact
Locations
Location 1:


Hours of Operation:*
Monday
to
Tuesday
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Wednesday
to
Thursday
to
Friday
to
Saturday
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Sunday
to

Location 2:


Hours of Operation:*
Monday
to
Tuesday
to
Wednesday
to
Thursday
to
Friday
to
Saturday
to
Sunday
to
Key Contacts:

Service Area by County

Please indicate Counties of Coverage (if entire county not covered indicate portion covered):

Documentation
Tax Information:
Pay to/Billing Address:

* If more than one tax ID# is utilized, please indicate on a separate attachment any locations that submit billing using tax ID #’s other than that listed above.

Insurance:

Please submit a copy of the policy face sheet indicating policy number, effective dates and coverage amounts.


Professional Liability Insurance:

Note: The information listed above, is required to initiate the provider credentialing process.
This is not confirmation of approval for network participation. It is the provider’s responsibility to update the data.

Instructions for organizational credentialing application
Please include the following with the application. Digital files should be compressed into a single zip file, and can be submitted below.
  1. W9
  2. Copy of current state operating license/certificate (if applicable)
  3. Copy of current certificate of accreditation from a recognized accrediting body or full CMS survey including corrective action plan (if applicable)
  4. Copy of current staff roster – Name and Title (Administrative and professional management staff only, if not provided in “Key Facility Contacts”)
  5. Copy of the signed Attestation Page
  6. Current Quality Assurance/Quality Improvement Policy/Program Description
  7. Inspection/State/DHS sanctions/Deficiency Reports for the past 3 years including corrective action plans (if applicable)
Affirmation and Release of Information

In order to evaluate this application for participation in the UPMC Health Plan (UPMCHP), I authorize your authorized representatives to consult with any third party which may have information bearing on the subject matter addressed by this Application. This includes the inspection or acquisition of any reports, records, recommendations or other documents or disclosures of third parties, e.g., JCAHO, insurance companies, professional liability companies, etc., that may be material to the questions in this Application.

I also authorize any third parties to release information to you and/or your authorized representatives upon request. I hereby release you and/or your authorized representatives, and any third parties, from any liability for any reports, records, recommendations, and other documents or disclosures involving me and this organization that are made, requested or received by you and/or your authorized representatives to, from, or by any third parties including otherwise privileged or confidential information, made or given in good faith and relating to the subject matter addressed by this Application.

I represent and warrant to UPMCHP that the information contained in the foregoing Application is true and complete to the best of my knowledge and belief. Any information entered into this Application which subsequently is found to be false, could result in UPMCHP’s refusal to enter into contract with this organization or termination of any contract with it.

I agree to inform UPMCHP promptly, in writing, if any material change in the information provided on this Application occurs, whether before or after my entering into an agreement with UPMCHP for the provision of medical services.

I warrant that I have the authority to sign this Application, on my own behalf, and on behalf of any entity or organization for which I am signing in a representative capacity. I agree that submission of this application does not constitute approval or acceptance by the UPMC Health Plan.

Original signature is required to complete this application. Stamped signatures are not acceptable.

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