"Provider Application" - Kansas

Provider Application is a legal document that was released by the Kansas Insurance Department - a government authority operating within Kansas.

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Provider Application
CAQH AUTOMATICALLY APPLIES MIXED-CASE FORMATTING,
CORRECT NUMBERS
A B C
1 2 3
CORRECT
X
INCORRECT
COMMON ABBREVIATIONS, AND ZIP CODE MATCHING. PLEASE
AND LETTERS
MARK
MARKS
MAKE CORRECTIONS ONLINE OR CALL THE HELP DESK.
Tips to avoid processing delays
Instructions
1. Complete only this application and its supplemental forms. Do not use another provider’s application.
Read all instructions
2. Use a blue or black ink ball-point pen only. Do not use a pencil or a felt-tip pen.
carefully prior to
3. Print legibly and inside the boxes provided based upon the examples given above.
submitting your
4. Do not enter more than 1 character per box. If necessary, write outside the provided spaces.
application.
5. Complete all sections that are applicable to you.
6. Some fields use “codes” to help you easily report information (e.g., schools, languages). Code lists are found on pages 36 - 43.
NOTE: Fields with asterisks (*) indicate that a response is required. All other fields will be considered not applicable if left blank.
SECTION 1
Personal Information and Professional IDs
Code list is found on page 36. Enter the
DO YOU PRACTICE EXCLUSIVELY WITHIN THE INPATIENT SETTING?*
Provider Type
associated 3-digit code in the space
YES
NO
(E.G. PATHOLOGISTS, ANESTHESIOLOGISTS, ER PHYSICIANS, NURSE
provided.*
PRACTITIONER, RADIOLOGISTS, PHYSICIAN ASSISTANT, ETC.)
Name
Do not use nicknames
or initials, unless they
LAST NAME*
SUFFIX (JR, III)
are part of your legal
name.
FIRST NAME*
MIDDLE NAME
HAVE YOU EVER USED ANOTHER NAME?*
YES
NO
IF YES, PLEASE LIST ALL OTHER NAMES USED AND THEIR DATES OF USE BELOW.
OTHER LAST NAME
SUFFIX (JR, III)
OTHER FIRST NAME
OTHER MIDDLE NAME
M M
D D
Y Y Y Y
M M
D D
Y Y Y Y
DATE STARTED USING OTHER NAME
DATE STOPPED USING OTHER NAME
General
Information
M M
D D
Y Y Y Y
DATE OF BIRTH*
GENDER*
MALE
FEMALE
Only enter a Foreign
National Identification
Number if you do not
have a SSN. Do not
enter National Provider
CITY OF BIRTH
STATE OF
COUNTRY OF
BIRTH
BIRTH
Identification (NPI)
Number here.
-
-
SSN*
Code lists are found on
FOREIGN NATIONAL IDENTIFICATION NUMBER (FNIN)
FNIN COUNTRY OF ISSUE
pages 36-43. Enter the
associated 3-digit code
in the space provided.
ENTER ALL NON-ENGLISH
LANGUAGES YOU SPEAK
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
Home Address
NUMBER
STREET
APT NUMBER
CITY
STATE
ZIP CODE
-
-
TELEPHONE
CAQH will use
NOTE:
this method for
E-MAIL
application follow-up.
-
-
PREFERRED METHOD OF CONTACT*
E-MAIL
FAX
FAX
3076
Page 01
REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
*
Provider Application
CAQH AUTOMATICALLY APPLIES MIXED-CASE FORMATTING,
CORRECT NUMBERS
A B C
1 2 3
CORRECT
X
INCORRECT
COMMON ABBREVIATIONS, AND ZIP CODE MATCHING. PLEASE
AND LETTERS
MARK
MARKS
MAKE CORRECTIONS ONLINE OR CALL THE HELP DESK.
Tips to avoid processing delays
Instructions
1. Complete only this application and its supplemental forms. Do not use another provider’s application.
Read all instructions
2. Use a blue or black ink ball-point pen only. Do not use a pencil or a felt-tip pen.
carefully prior to
3. Print legibly and inside the boxes provided based upon the examples given above.
submitting your
4. Do not enter more than 1 character per box. If necessary, write outside the provided spaces.
application.
5. Complete all sections that are applicable to you.
6. Some fields use “codes” to help you easily report information (e.g., schools, languages). Code lists are found on pages 36 - 43.
NOTE: Fields with asterisks (*) indicate that a response is required. All other fields will be considered not applicable if left blank.
SECTION 1
Personal Information and Professional IDs
Code list is found on page 36. Enter the
DO YOU PRACTICE EXCLUSIVELY WITHIN THE INPATIENT SETTING?*
Provider Type
associated 3-digit code in the space
YES
NO
(E.G. PATHOLOGISTS, ANESTHESIOLOGISTS, ER PHYSICIANS, NURSE
provided.*
PRACTITIONER, RADIOLOGISTS, PHYSICIAN ASSISTANT, ETC.)
Name
Do not use nicknames
or initials, unless they
LAST NAME*
SUFFIX (JR, III)
are part of your legal
name.
FIRST NAME*
MIDDLE NAME
HAVE YOU EVER USED ANOTHER NAME?*
YES
NO
IF YES, PLEASE LIST ALL OTHER NAMES USED AND THEIR DATES OF USE BELOW.
OTHER LAST NAME
SUFFIX (JR, III)
OTHER FIRST NAME
OTHER MIDDLE NAME
M M
D D
Y Y Y Y
M M
D D
Y Y Y Y
DATE STARTED USING OTHER NAME
DATE STOPPED USING OTHER NAME
General
Information
M M
D D
Y Y Y Y
DATE OF BIRTH*
GENDER*
MALE
FEMALE
Only enter a Foreign
National Identification
Number if you do not
have a SSN. Do not
enter National Provider
CITY OF BIRTH
STATE OF
COUNTRY OF
BIRTH
BIRTH
Identification (NPI)
Number here.
-
-
SSN*
Code lists are found on
FOREIGN NATIONAL IDENTIFICATION NUMBER (FNIN)
FNIN COUNTRY OF ISSUE
pages 36-43. Enter the
associated 3-digit code
in the space provided.
ENTER ALL NON-ENGLISH
LANGUAGES YOU SPEAK
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
LANGUAGE CODE
Home Address
NUMBER
STREET
APT NUMBER
CITY
STATE
ZIP CODE
-
-
TELEPHONE
CAQH will use
NOTE:
this method for
E-MAIL
application follow-up.
-
-
PREFERRED METHOD OF CONTACT*
E-MAIL
FAX
FAX
3076
Page 01
REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
*
REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
*
Section 1
Personal Information and Professional IDs (Continued)
Professional
M M D D Y Y Y Y
IDs
FEDERAL DEA NUMBER
DEA ISSUE DATE
Include all state
licenses, DEA
M M D D Y Y Y Y
Registration and State
Controlled Dangerous
DEA STATE OF REGISTRATION
DEA EXPIRATION DATE
Substance (CDS)
certification numbers.
M M D D Y Y Y Y
Provide all current and
CDS CERTIFICATE NUMBER
CDS ISSUE DATE
previous licenses/
certifications.
M M D D Y Y Y Y
CDS STATE OF REGISTRATION
CDS EXPIRATION DATE
Non-licensed
professionals should
M M D D Y Y Y Y
enter certification/
registration number in
STATE LICENSE NUMBER
LICENSE ISSUING STATE
LICENSE ISSUE DATE
the space provided for
IF THIS IS A STATE LICENSE, ARE YOU
license number.
M M D D Y Y Y Y
YES
NO
CURRENTLY PRACTICING IN THIS STATE?
If you have additional
LICENSE EXPIRATION DATE
Professional IDs to
report, use the
Code list is found on page 36;
Code list is found on page 36;
use license status codes. Enter
use provider type codes. Enter
Professional IDs
3-digit code in space provided.
3-digit code in space provided.
Supplemental Form on
LICENSE STATUS CODE
LICENSE TYPE
page 19.
M M D D Y Y Y Y
STATE LICENSE NUMBER
LICENSE ISSUING STATE
LICENSE ISSUE DATE
IF THIS IS A STATE LICENSE, ARE YOU
YES
NO
M M D D Y Y Y Y
CURRENTLY PRACTICING IN THIS STATE?
LICENSE EXPIRATION DATE
Code list is found on page 36;
Code list is found on page 36;
use license status codes. Enter
use provider type codes. Enter
3-digit code in space provided.
3-digit code in space provided.
LICENSE STATUS CODE
LICENSE TYPE
Other ID
ARE YOU A PART-
YES
NO
ICIPATING MEDICARE
Numbers
PROVIDER?*
MEDICARE NUMBER
UPIN
ARE YOU A PART-
If you have additional
ICIPATING MEDICAID
YES
NO
Professional IDs to
PROVIDER?*
report, use the
MEDICAID NUMBER
MEDICAID STATE
Professional IDs
Supplemental Form on
page 19.
NATIONAL PROVIDER IDENTIFICATION (NPI) NUMBER
USMLE NUMBER (WITHOUT HYPHENS)
WORKERS COMPENSATION NUMBER
0
M M D D Y Y Y Y
ECFMG NUMBER (NON-U.S./CANADIAN GRADUATE ONLY)
ECFMG CERTIFICATE ISSUE DATE (NON-U.S./CANADIAN GRADUATE ONLY)
3077
Page 02
REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
*
Section 2
Education and Training
Undergraduate
UNDERGRADUATE SCHOOL
School(s)
Provide the appropriate
information for the
OFFICIAL NAME OF UNDERGRADUATE SCHOOL
school that issued your
undergraduate degree
and all schools
ADDRESS
attended.
CITY
STATE
ZIP/POSTAL CODE
Professional
-
-
-
-
School(s)
COUNTRY CODE
TELEPHONE
FAX
Provide the appropriate
information for the
M M Y Y Y Y
M M Y Y Y Y
school that issued your
professional degree.
START DATE
END DATE (GRADUATION DATE)
DEGREE AWARDED
Fifth Pathway Graduates
DID YOU COMPLETE YOUR
UNDERGRADUATE EDUCATION
YES
NO
please complete the
AT THIS SCHOOL?
following sections: U.S.
School that issued your
certificate, the Non-U.S.
GRADUATE TYPE*:
School where you
attended, and the Fifth
Pathway institution
U.S. OR CANADIAN GRADUATE
NON-U.S./CANADIAN GRADUATE
FIFTH PATHWAY GRADUATE
where you completed
your training on
U.S. OR CANADIAN SCHOOL
Supplemental Page 20.
Code lists are found on
SCHOOL CODE (U.S./
NAME OF U.S./
CANADIAN ONLY)
CANADIAN SCHOOL:
pages 36-43. Enter the
associated 3-digit code
in the space provided.
M M Y Y Y Y
M M Y Y Y Y
If you have additional
START DATE*
END DATE (GRADUATION DATE)*
DEGREE AWARDED
Undergraduate or
Professional Schools to
DID YOU COMPLETE YOUR
report, use the
YES
NO
GRADUATE EDUCATION AT THIS
SCHOOL?
Education Supplemental
Form on page 20.
NON - U.S. OR CANADIAN SCHOOL
OFFICIAL NAME OF NON-U.S. PROFESSIONAL SCHOOL
ADDRESS
CITY
COUNTRY CODE
POSTAL CODE
M M Y Y Y Y
M M Y Y Y Y
START DATE*
END DATE (GRADUATION DATE)*
DEGREE AWARDED
DID YOU COMPLETE YOUR
YES
NO
GRADUATE EDUCATION AT THIS
SCHOOL?
3078
Page 03
REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
*
REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
*
Section 2
Education and Training (Continued)
Training
List all training
SCHOOL CODE (E.G.,
programs you
AFFILIATED MEDICAL
attended. Use one
SCHOOL)
section per institution.
INSTITUTION/HOSPITAL NAME (USE BOTH LINES IF REQUIRED)
If you have additional
post-graduate training
programs, use the
NUMBER
STREET
SUITE/BUILDING
Supplemental Training
Form on page 21.
CITY
STATE
ZIP/POSTAL CODE
Please explain on the
Supplemental
Professional / Work
-
-
-
-
History Gap Form on
page 33 any training
TELEPHONE
FAX
COUNTRY CODE
gap(s) of three (3)
months or greater, or
DID YOU COMPLETE THIS TRAINING PROGRAM AT THIS
YES
NO
INSTITUTION?
any gap(s) of a shorter
duration if required by
(IF NOT, PLEASE USE THE SPACE BELOW TO EXPLAIN.)
the organization for
which you are being
credentialed.
Code lists are found on
pages 36-43. Enter the
associated 3-digit code
in the space provided.
INTERNSHIP/
List each
M M Y Y Y Y
M M Y Y Y Y
FELLOWSHIP
OTHER
RESIDENCY
department
START DATE
END DATE
separately, if
applicable.
List
DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)
Internship/
Residency,
Fellowship
and Other
NAME OF DIRECTOR
programs
separately.
INTERNSHIP/
M M Y Y Y Y
M M Y Y Y Y
FELLOWSHIP
OTHER
RESIDENCY
START DATE
END DATE
DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)
NAME OF DIRECTOR
INTERNSHIP/
M M Y Y Y Y
M M Y Y Y Y
FELLOWSHIP
OTHER
RESIDENCY
START DATE
END DATE
DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)
NAME OF DIRECTOR
3080
Page 04
REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
*
REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
*
Section 3
Professional / Medical Specialty Information
Primary
INITIAL
DO YOU WISH TO
SPECIALTY
M M D D Y Y Y Y
BE LISTED IN
HMO
YES
NO
CERTIFICATION
CODE
Specialty
THE DIRECTORY
DATE
UNDER THIS
RECERTIFICATION
SPECIALTY?
BOARD
M M D D Y Y Y Y
Code lists are found on
YES
NO
YES
NO
DATE
PPO
CERTIFIED?
(IF APPLICABLE)
pages 36-43. Enter the
associated 3-digit code
CERTIFYING
EXPIRATION DATE
in the space provided.
M M D D Y Y Y Y
YES
NO
BOARD
POS
(IF APPLICABLE)
CODE
IF NOT
I HAVE TAKEN
I INTEND TO SIT FOR AN
I DO NOT INTEND TO TAKE
BOARD
EXAM, RESULTS
EXAM ON
A CERTIFYING BOARD EXAM.
CERTIFIED
PENDING FOR
(SELECT
ONE)
M M D D Y Y Y Y
CERTIFYING BOARD CODE
IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE A CERTIFYING BOARD EXAM, PLEASE USE THE
FOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.
Secondary
INITIAL
DO YOU WISH TO
SPECIALTY
M M D D Y Y Y
Y
HMO
YES
NO
BE LISTED IN
CERTIFICATION
CODE
Specialty
THE DIRECTORY
DATE
UNDER THIS
RECERTIFICATION
SPECIALTY?
BOARD
YES
NO
M M D D Y Y Y Y
YES
NO
DATE
Code lists are found on
PPO
CERTIFIED?
(IF APPLICABLE)
pages 36-43. Enter the
associated 3-digit code
CERTIFYING
EXPIRATION DATE
in the space provided.
M M D D Y Y Y Y
YES
NO
POS
BOARD
(IF APPLICABLE)
CODE
If you have additional
IF NOT
I HAVE TAKEN
I INTEND TO SIT FOR AN
Professional / Medical
I DO NOT INTEND TO TAKE
BOARD
EXAM, RESULTS
EXAM ON
A CERTIFYING BOARD EXAM.
Specialties to report,
CERTIFIED
PENDING FOR
use the Additional
(SELECT
ONE)
Specialties
M M D D Y Y Y Y
Supplemental Form on
page 22.
CERTIFYING BOARD CODE
IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE A CERTIFYING BOARD EXAM, PLEASE USE THE
FOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.
3081
Page 05
REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.
*
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