Provider Network Application Checklist
The following items are required:
- All applicable items on the Application are complete and legible
- Signed and dated Consent and Release of Liability
- Signed and dated Authorization for Recipient Rights Check
- Signed and dated Authorization to Obtain Information & General Release
- Copy of picture Identification
- Written explanations for any privilege, licensure, or malpractice history “Yes” answers
- Copy of Licensure/Certification necessary to support requested services/privileges
- Copies of all professional licenses/certifications for all staff
- Copy of the organization’s Accreditation Certificate and most recent survey report
- Copy of the organization’s Policies & Practices, with corresponding page numbers
- Copy of current Professional/General Liability Policy
- Federal W-9 Form - Request for Taxpayer Identification Number and Certification
- Disclosure of Ownership & Controlling Interest Statement