Physician

Tikka Attach

MC-5
DEC 05 Page 1 of 14 Pages.

New Jersey Universal Physician Application
(Please type or print)

SECTION 1
Personal Information

Physician Name (Last) (First) (MI) (Jr., Sr., etc.)


Professional Degree(s) (MD, DO,
DDS, DMD, DPM, DC)



Social Security Number


Other Name Used


Years Associated with
Former Name



Other Name Used


Years Associated with
Former Name


Date of Birth (mm/dd/yyyy)

/ /
Gender

Male Female
Are you eligible to work in the United States?

Yes No

Home Mailing Address


City


State


Zip Code


Practice Location Information
Type of Service Provided

Primary Care Specialist Non-Primary Care Specialist

Physician Group Name/Practice Name (to appear in the directory)


Group/Corporate Name (as it appears on W-9), if different from Group
Name/Practice Name

Primary Office Mailing Address


City


State


Zip Code


Primary Office Telephone No.


Primary Office Fax No.


Primary Office E-mail Address


Tax ID Number and Associated Individual Group Number and Name for This Location


Are you currently practicing at the above location?
Yes No

If No, what is your expected start date?


Other Office Street Address


City


State


Zip Code


Telephone No.


Fax No.


E-mail Address


Do you want this site listed in the Directory?
Yes No

Tax ID Number and Associated Individual Group Number and Name for This Location


Other Office Street Address


City


State


Zip Code


Telephone No.


Fax No.


E-mail Address


Do you want this site listed in the Directory?
Yes No

Tax ID Number and Associated Individual Group Number and Name for This Location


Correspondence Office Street Address


City


State


Zip Code


Telephone No.


Fax No.


E-mail Address


If you have additional offices, please submit an attachment containing the above information and check this box:



MC-5
DEC 05 Page 2 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

License and Other Identification Numbers
(License Information - Include all license(s) and certifications in all States where you are currently or have previously been licensed.)

Type State(s) of Registration
Do You Currently

Practice In This State?
License/Certificate

Number
Expiration

Date N/A

License
Yes No

License
Yes No

DEA Registration Certificate
Yes No

CDS Registration Certificate
Yes No

Other (CDS/DEA) (Specify)
Yes No

UPIN


National Provider ID
(when available)



Are you a participating
Medicare Provider?



Medicare Provider No.


Are you a participating
Medicaid Provider?



Medicaid Provider No.


International Medical Graduates: Are you certified by the Educational
Council for Foreign Medical Graduates (ECFMG)?

Yes No

If yes, ECFMG Number


ECFMG Issue Date


Medical Education
School Issuing Professional Degree (Medical, Dental, Chiropractic)


Degree


Attendance Dates



Address


City


State/Country


Zip Code


If you have attended additional schools, please submit an attachment containing the above information and check this box:
Post-Graduate Education

Internship Fellowship
Residency Teaching Appointment

Institution Name


Address


City


State


Zip Code


Specialty


Start Date (Month/Year)


End Date (Month/Year)


Post-Graduate Education
Internship Fellowship
Residency Teaching Appointment

Institution Name


Address


City


State


Zip Code


Specialty


Start Date (Month/Year)


End Date (Month/Year)


Post-Graduate Education
Internship Fellowship
Residency Teaching Appointment

Institution Name


Address


City


State


Zip Code


Specialty


Start Date (Month/Year)


End Date (Month/Year)


If you completed additional training, please submit an attachment containing the above information and check this box:
Other Graduate Level Education for Which a Degree Was Obtained -
Type of Program (Psychology, Public Health, MBA, etc.)



Institution Name


Address


City


State


Zip Code


Degree Obtained


Date of Graduation (Month/Year)




MC-5
DEC 05 Page 3 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Professional/Medical Specialty Information

Primary Specialty


Board Certified?
Yes No

Name of Certifying Board


Initial Certification Date


Recertification Date (s) (if applicable)


Expiration Date (if applicable)


If not Board Certified, indicate any of the following that apply:
I have taken exam, results pending for: (board)
I am intending to sit for the Boards on: (date)
I am not planning to take the Boards.

Do you wish to be listed in the directory under this specialty?
HMO Yes No
PPO Yes No
POS Yes No

Secondary Specialty


Board Certified?
Yes No

Name of Certifying Board


Initial Certification Date


Recertification Date (s) (if applicable)


Expiration Date (if applicable)


If not Board Certified, indicate any of the following that apply:
I have taken exam, results pending for: (board)
I am intending to sit for the Boards on: (date)
I am not planning to take the Boards.

Do you wish to be listed in the directory under this specialty?
HMO Yes No
PPO Yes No
POS Yes No

Additional Specialty


Board Certified?
Yes No

Name of Certifying Board


Initial Certification Date


Recertification Date (s) (if applicable)


Expiration Date (if applicable)


If not Board Certified, indicate any of the following that apply:
I have taken exam, results pending for: (board)
I am intending to sit for the Boards on: (date)
I am not planning to take the Boards.

Do you wish to be listed in the directory under this specialty?
HMO Yes No
PPO Yes No
POS Yes No

List Additional Areas of Professional Practice, Interest or Focus (HIV/AIDS, etc.)


Hospital Affiliations and Privileges
Do you have hospital privileges?

Yes No
If you do not admit patients, what admitting arrangements do you have?


If you have privileges, please complete the section below. Include all hospitals where you have privileges.
Primary Hospital where you have Admitting Privileges


Telephone Number



Address


City


State


Zip Code


Full Unrestricted Privileges
Yes No

Type of Privileges


Are Privileges Temporary?
Yes No

Of the total admissions to all hospitals in the
past year, what percentage is to this specific
hospital?

Other Hospital Where you Have Privileges


Telephone Number


Address


City


State


Zip Code


Full Unrestricted Privileges
Yes No

Type of Privileges


Are Privileges Temporary?
Yes No

Of the total admissions to all hospitals in the
past year, what percentage is to this specific
hospital?

Other Hospital Where you Have Privileges


Telephone Number


Address


City


State


Zip Code


Full Unrestricted Privileges
Yes No

Type of Privileges


Are Privileges Temporary?
Yes No

Of the total admissions to all hospitals in the
past year, what percentage is to this specific
hospital?

Additional Hospital Where you Have Privileges


Telephone Number


Address


City


State


Zip Code


Full Unrestricted Privileges
Yes No

Type of Privileges


Are Privileges Temporary?
Yes No

Of the total admissions to all hospitals in the
past year, what percentage is to this specific
hospital?

If you have additional hospital affiliations, please submit an attachment containing the above information and check this box:



MC-5
DEC 05 Page 4 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
List all other hospitals where you have previously had privileges.
Hospital Name


Dates of Affiliation



Address


City


State


Zip Code


Hospital Name


Dates of Affiliation


Address


City


State


Zip Code


If you have other previous hospital affiliations, please submit an attachment containing the above information and check this box:

Work History
Include chronological work history since completion of training.
Practice/Employer Name


Start Date/End Date



Address


City


State


Zip Code


Practice/Employer Name


Start Date/End Date


Address


City


State


Zip Code


Practice/Employer Name


Start Date/End Date


Address


City


State


Zip Code


Practice/Employer Name


Start Date/End Date


Address


City


State


Zip Code


For additional work history, please submit an attachment containing the above information and check this box:
Please provide an explanation of any gaps greater than six months in each work history.
Date


Explanation



Date


Explanation


Are you currently on active military duty or on military reserve?
Yes No



References
Please provide three professional references that are not partners in your own group practice and are not relatives.

Name Street Address City, State, Zip Code










MC-5
DEC 05 Page 5 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Professional Liability Insurance Coverage
Are you self-insured?

Yes No

Name of Current Malpractice Insurance Carrier or Self-Insured Entity


Telephone Number


Effective Date


Expiration Date


Address


City


State


Zip Code


Policy Number


Amount of Coverage per Occurrence


Amount of Coverage Aggregate


Type of Coverage
Individual
Shared

Length of Time with
Carrier

Name of Previous Malpractice Insurance Carrier or Self-Insured Entity


Telephone Number


Effective Date


Expiration Date


Address


City


State


Zip Code


Policy Number


Amount of Coverage per Occurrence


Amount of Coverage Aggregate


Type of Coverage
Individual
Shared

Length of Time with
Carrier



Status/Role in Practice

Owner Partner Employee Officer Shareholder



Interests in Outside Clinical Lab(s)
If you own/co-own, or have interests in any other outside clinical lab, please fill in below:
Legal Billing Name


TIN (Attach copy of W-9)


Clinical Description



Please provide a summary pattern for this business:




Office Coverage
List names of colleague(s) providing regular coverage and his/her specialty(ies).

Name Provider Specialty









Partners
List full names of all partners in your practice (attach list for large group).

Name (Last, First, MI) Name (Last, First, MI)













MC-5
DEC 05 Page 6 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Other Practice Information (specify for each site)
Site 1 Site 2

Office Address:


Office Address:


Type of Practice:
Solo Single Specialty Group Multi-Specialty Group

Type of Practice:
Solo Single Specialty Group Multi-Specialty Group

Office Manager or Business Office Staff Contact:: Office Manager or Business Office Staff Contact::
Name: Name:
Telephone No.: Telephone No.:
Fax No.: Fax No.:

Credentialing Contact (if different from above): Credentialing Contact (if different from above):
Name: Name:
Telephone No.: Telephone No.:
Fax No.: Fax No.:
E-mail: E-mail:
Address: Address:
City: City:
State: Zip: State: Zip:

Billing Information: Billing Information:
Billing Rep. Name: Billing Rep. Name:
Address: Address:
City: City:
State: Zip: State: Zip:
Telephone No.: Telephone No.:
Fax No.: Fax No.:
E-mail: E-mail:
Dept. Name if Hosp.-Based: Dept. Name if Hosp.-Based:
Check should be payable to Check should be payable to

Do you have capability of electronic billing? Yes No Do you have capability of electronic billing? Yes No

Office Business Hours (hours patients are seen): Office Business Hours (hours patients are seen):

Day
No

Office
Hours

Morning Afternoon Evening Day
No

Office
Hours

Morning Afternoon Evening

MON MON
TUES TUES
WED WED
THUR THUR

FRI FRI
SAT SAT
SUN SUN

After hours, back office phone number
for health plan business use only:

After hours, back office phone number
for health plan business use only:

Do you provide 24 hour/7 day a
week phone coverage for this site? Yes No

If yes, indicate type:
Answering service
Voice mail with instructions to call answering service
Voice mail with other instructions

Do you provide 24 hour/7 day a
week phone coverage for this site? Yes No

If yes, indicate type:
Answering service
Voice mail with instructions to call answering service
Voice mail with other instructions

(Continue on next page.)



MC-5
DEC 05 Page 7 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Other Practice Information (specify for each site)

(Continued from previous page.)

Site 1, Continued Site 2, Continued

Do you accept new patients into the practice? ..... Yes No
-All new patients?............................................... Yes No
-Existing patients with change of payor?............ Yes No
-New patients from physician referral?............... Yes No
-New Medicare patients? ................................... Yes No
-New Medicaid patients?.................................... Yes No

Do you accept new patients into the practice? ..... Yes No
-All new patients?............................................... Yes No
-Existing patients with change of payor?............ Yes No
-New patients from physician referral?............... Yes No
-New Medicare patients? ................................... Yes No
-New Medicaid patients?.................................... Yes No

If this information varies by health plan, provide explanation:


If this information varies by health plan, provide explanation:


Are there any practice limitations? Yes No
If yes, indicate limitations below:

Are there any practice limitations? Yes No
If yes, indicate limitations below:

Gender: Male Only Female Only N/A Gender: Male Only Female Only N/A
Patient Age Limitation (List Ages): N/A Patient Age Limitation (List Ages): N/A

List Other Limitations: List Other Limitations:


Do mid-level practitioners such as nurse
practitioners, physician assistants, midwives,
social workers or other non-physician providers
care for patients in your practice? Yes No
If yes, provide the following information for each staff member:

Do mid-level practitioners such as nurse
practitioners, physician assistants, midwives,
social workers or other non-physician providers
care for patients in your practice? Yes No
If yes, indicate limitations below:

Name: Name:
Professional Designation: Professional Designation:
State License Number: State License Number:
Name: Name:
Professional Designation: Professional Designation:
State License Number: State License Number:

Please attach a list of any additional mid-level practitioners. Please attach a list of any additional mid-level practitioners.

Non-English Languages spoken: Non-English Languages spoken:
by health care professional: by health care professional:
by office personnel: by office personnel:
Are interpreters available? Yes No Are interpreters available? Yes No
If yes, specify languages: If yes, specify languages:


Does this office meet ADA
accessibility standards? Yes No

Does this office meet ADA
accessibility standards? Yes No

Does this site provide handicapped accessibility for each of the
following:

Building Yes No
Parking Yes No
Restroom Yes No

Does this site provide handicapped accessibility for each of the
following:

Building Yes No
Parking Yes No
Restroom Yes No

Other: Other:

Does this site have other services for the disabled?
Yes No
If yes, indicate type:

Text Telephony - TTY Yes No
American Sign Language-ASL Yes No
Mental/Physical Impairment Services Yes No

Does this site have other services for the disabled?
Yes No
If yes, indicate type:

Text Telephony - TTY Yes No
American Sign Language-ASL Yes No
Mental/Physical Impairment Services Yes No

Other: Other:

(Continue on next page.)



MC-5
DEC 05 Page 8 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Other Practice Information (specify for each site)

(Continued from previous page.)

Site 1, Continued Site 2, Continued
Is this site accessible by public transportation?

Yes No
Bus Yes No
Subway Yes No
Regional Train Yes No

Is this site accessible by public transportation?
Yes No
Bus Yes No
Subway Yes No
Regional Train Yes No

Other: Other:

Does this site provide childcare services? Yes No Does this site provide childcare services? Yes No
Does this office qualify
as a minority business enterprise? Yes No

Does this office qualify
as a minority business enterprise? Yes No

Do you or does someone in your office have the following
certifications? (Indicate for each office location.)

Do you or does someone in your office have the following
certifications? (Indicate for each office location.)

Yes No Exp.Date Yes No Exp.Date
BLS (Basic Life Support) BLS (Basic Life Support)
ACLS (Advanced Cardiac Life Support) ACLS (Advanced Cardiac Life Support)
ALSO (Advanced Life Support in OB) ALSO (Advanced Life Support in OB)
PALS (Pediatric Advanced Life Support) PALS (Pediatric Advanced Life Support)
ATLS (Advanced Trauma Life Support) ATLS (Advanced Trauma Life Support)
NALS (Neonatal Advanced Life Support) NALS (Neonatal Advanced Life Support)
CPR (Cardio-Pulmonary Resuscitation) CPR (Cardio-Pulmonary Resuscitation)

Does your site provide any of the following services on site?
(Indicate for each office location.)

Does your site provide any of the following services on site?
(Indicate for each office location.)

Laboratory Services Yes No Laboratory Services Yes No
Certificate of Participation from CLIA or
another accrediting/certifying program
[AAFP, COLA, CAP, Medical Laboratory
Evaluation (MLE)] Program Yes No

Certificate of Participation from CLIA or
another accrediting/certifying program
[AAFP, COLA, CAP, Medical Laboratory
Evaluation (MLE)] Program Yes No

If yes, list program: If yes, list program:
Radiology Services Yes No Radiology Services Yes No
X-Ray Certification Yes No X-Ray Certification Yes No
If yes, include type: If yes, include type:
EKG?s Yes No EKG?s Yes No
Care of Minor Lacerations Yes No Care of Minor Lacerations Yes No
Pulmonary Function Testing Yes No Pulmonary Function Testing Yes No
Allergy Injections Yes No Allergy Injections Yes No
Allergy Skin Testing Yes No Allergy Skin Testing Yes No
Office Gynecology (Routine Pelvic/Pap) Yes No Office Gynecology (Routine Pelvic/Pap) Yes No
Drawing Blood Yes No Drawing Blood Yes No
Age Appropriate Immunizations Yes No Age Appropriate Immunizations Yes No
Flexible Sigmoidoscopy Yes No Flexible Sigmoidoscopy Yes No
Tympanometry/Audiometry Screening Yes No Tympanometry/Audiometry Screening Yes No
Asthma Treatment Yes No Asthma Treatment Yes No
Osteopathic Manipulation Yes No Osteopathic Manipulation Yes No
IV Hydration/Treatment Yes No IV Hydration/Treatment Yes No
Cardiac Stress Tests Yes No Cardiac Stress Tests Yes No
Physical Therapy Yes No Physical Therapy Yes No

Additional Office Procedures Provided (incl. surgical procedures)


Additional Office Procedures Provided (incl. surgical procedures)


Is anesthesia administered in your office? Yes No
If Yes, what class or category of anesthesia do you use?

Is anesthesia administered in your office? Yes No
If Yes, what class or category of anesthesia do you use?


Who administers it? Who administers it?


For additional office sites, please submit an attachment containing the above information and check this box:



MC-5
DEC 05 Page 9 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Patient Scheduling

What is patient wait time for emergency care? .................................................
What is patient wait time for urgent care?.........................................................
What is patient wait time for symptomatic care? ...............................................
What is patient wait time for scheduling routine visits? .....................................
What is patient wait time for scheduling routine care? ......................................
What is average wait time for patients between waiting room and examination?
What is average wait time in minutes for returning a patient?s call?..................



Required Attachments or Supplemental Information

Please attach hard copy or scanned documents of the following:
? Copy(ies) of DEA registration certificate(s)
? Copy of state Controlled Dangerous Substance (CDS) registration

certificate(s)
? Copy of current professional liability insurance policy face sheet,

showing expiration dates, limits and provider?s name
? Copy(ies) of W-9(s) for verification of each tax identification number

used
? Copy of workers compensation certificate of coverage, if applicable



SECTION 2 - DISCLOSURE QUESTIONS
Please answer each question and include an explanation for any question answered ?Yes.?

Licensure

1. Has your license to practice, in your profession, ever been denied, suspended, revoked,
restricted, voluntarily surrendered while under investigation or have you ever been subject to
a consent order, probation or any conditions or limitations by any state licensing board?................... Yes No

2. Have you ever received a reprimand or been fined by any state licensing board?.............................. Yes No

Hospital Privileges and Other Affiliations

3. Have your clinical privileges at any hospital or healthcare institution ever been denied,
suspended, revoked, restricted, denied renewal or subject to probationary or to other
disciplinary conditions (for reasons other than non-completion of medical records when
quality of care was not adversely affected) or have proceedings toward any of those ends
been instituted or recommended by any hospital or healthcare institution, medical staff or
committee, or governing board? .......................................................................................................... Yes No

4. Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while
under investigation?............................................................................................................................. Yes No

5. Have you ever been terminated for cause or not renewed for cause from participation, or
been subject to any disciplinary action, by any managed care organizations (including HMOs,
PPOs, or provider organizations such as IPAs, PHOs)? ..................................................................... Yes No

Education, Training and Board Certification

6. Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked
to resign during an internship, residency, fellowship, preceptorship or other clinical education
program? If you are currently in a training program, have you been placed on probation,
disciplined, formally reprimanded, suspended or asked to resign? ..................................................... Yes No

7. Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated
your status as a student or employee in any internship, residency, fellowship, preceptorship,
or other clinical education program?.................................................................................................... Yes No

8. Have any of your board certifications or eligibility ever been revoked? ............................................... Yes No

9. Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s)
while under investigation? ................................................................................................................... Yes No



MC-5
DEC 05 Page 10 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

DEA or CDS Certification/Authorization

10. Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s)
or authorization(s) ever been denied, suspended, revoked, restricted, denied renewal, or
voluntarily relinquished? ...................................................................................................................... Yes No

Medicare, Medicaid or Other Governmental Program Participation

11. Have you ever been disciplined, excluded from, debarred, suspended, reprimanded,
sanctioned, censured, disqualified, subject to a recovery action or otherwise restricted in
regard to participation in the Medicare or Medicaid program, or in regard to other federal or
state governmental health care plans or programs?............................................................................ Yes No

Other Sanctions or Investigations

12. Are you currently or have you ever been the subject of an investigation by any hospital,
licensing authority, DEA or CDS authorizing entities, education or training program, Medicare
or Medicaid program, or any other private, federal or state health program? ...................................... Yes No

13. To your knowledge, has information pertaining to you ever been reported to the National
Practitioner Data Bank or Healthcare Integrity and Protection Data Bank? ......................................... Yes No

14. Have you ever received sanctions from or been the subject of investigation by any regulatory
agencies (e.g., CLIA, OSHA, etc.)? .................................................................................................... Yes No

15. Has a patient, employee, or co-worker ever accused you of sexual harassment or other
illegal misconduct that resulted in an investigation, sanction or other formal action? .......................... Yes No

16. Have you ever been investigated, sanctioned, reprimanded or cautioned by a military
hospital, facility, or agency, or voluntarily terminated or resigned while under investigation by
a hospital or healthcare facility of any military agency? ....................................................................... Yes No

Professional Liability Insurance Information and Claims History

17. Has your professional liability coverage ever been cancelled, restricted, declined or not
renewed by the carrier based on your individual liability history? ........................................................ Yes No

18. Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by
your professional liability insurance carrier, based on your individual liability history? ........................ Yes No

Malpractice Claims History

19. Have you ever had any malpractice actions (pending, settled, dropped, dismissed, arbitrated,
mediated or litigated)? If yes, provide information for each case on the attached form located
at the end of the Disclosure questions (list all separately). .................................................................. Yes No

For any malpractice actions, please complete addendum and check this box:

Criminal/Civil History
(Note: A criminal record will not necessarily be a bar to acceptance. Decisions will be made by each health plan or credentialing
organization based upon all relevant circumstances, including the nature of the crime.)

20. Have you ever been arrested, charged or indicted for, convicted of, pled guilty to, or pled
nolo contendere to any felony, crime or other offense in the last ten years or been found
liable or responsible for or named as a defendant in any civil offense that is reasonably
related to your qualifications, competence, functions, or duties as a medical professional? ............... Yes No

21. Have you ever been arrested, charged or indicted for, convicted of, pled guilty to, or pled
nolo contendere to any felony, crime or other offense in the last ten years or been found
liable or responsible for or been named as a defendant in any civil offense that alleged fraud,
an act of violence, child abuse or a sexual offense or sexual misconduct? ......................................... Yes No

22. Have you ever been court-martialed for actions related to your duties as a medical
professional? ....................................................................................................................................... Yes No





MC-5
DEC 05 Page 11 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Ability to Perform Job

23. Are you currently engaged in the illegal use of drugs? (?Currently" means sufficiently recent
to justify a reasonable belief that the use of drugs may have an ongoing impact on one?s
ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks
before the date of application, rather that it has occurred recently enough to indicate the
individual is actively engaged in such conduct. ?Illegal use of drugs? refers to drugs whose
possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. ?
812.22 It ?does not include the use of a drug taken under supervision by a licensed health
care professional, or other uses authorized by the Controlled Substances Act or other
provision of Federal law.? The term does include, however, the unlawful use of prescription
controlled substances.)........................................................................................................................ Yes No

24. Do you use any chemical substances that would in any way impair or limit your ability to
practice medicine and perform the functions of your job with reasonable skill and safety? ................. Yes No

25. Do you have any reason to believe that you would pose a risk to the safety or well being of
your patients? ...................................................................................................................................... Yes No

26. Are you able to perform the essential functions of a practitioner in your area of practice with
or without reasonable accommodation? .............................................................................................. Yes No


Please provide information below for Malpractice Actions indicated for Disclosure Question #19.

Date of occurrence:

Date claim was filed:

Claim/case status:



Professional liability carrier involved:

Address:

Telephone Number:

Policy Number:

Amount of award or settlement and amount paid:
Method of resolution:


Dismissed Settled (with prejudice) Settled (without prejudice)
Judgment for defendant(s) Judgment for plaintiff(s) Mediation or arbitration

Description of allegations:







Were you primary defendant or co-defendant?

Number of other co-defendants:

Your involvement in case (attending, consulting, etc.):

Description of alleged injury to the patient:







To the best of your knowledge, is this case included in the National Practitioner Data Bank (NPDB)? Yes No






MC-5
DEC 05 Page 12 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)


Please provide information below for any Disclosure Questions in Section II answered ?Yes.?
Question

No. Explanation











Provider Initials: Date:



MC-5
DEC 05 Page 13 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

SECTION 3 - AUTHORIZATION, ATTESTATION AND RELEASE


I understand and agree that, as part of the credentialing application process for participation and/or clinical
privileges (hereinafter, referred to as ?Participation?) at or with
(indicate managed care company(s) to which you are applying) (hereinafter, individually referred to as the
?Entity?), and any of the Entity?s affiliated entities, I am required to provide sufficient and accurate information for a
proper evaluation of my current licensure, relevant training and/or experience, clinical competence, health status,
character, ethics, and any other criteria used by the Entity for determining initial and ongoing eligibility for
Participation. Each Entity and its representatives, employees, and agent(s) acknowledge that the information
obtained relating to the application process will be held confidential to the extent permitted by law.

I acknowledge that each Entity has its own criteria for acceptance, and I may be accepted or rejected by each
independently. I further acknowledge and understand that my cooperation in obtaining information and my
consent to the release of information do not guarantee that any Entity will grant me clinical privileges or contract
with me as a provider of services. I understand that my application for Participation with the Entity is not an
application for employment with the Entity and that acceptance of my application by the Entity will not result in my
employment by the Entity.


Authorizations


Investigation Concerning Application for Participation: I hereby authorize the following individuals including,
without limitation, the Entity, its representatives, employees, and/or designated agent(s); the Entity?s affiliated
entities and their representatives, employees, and/or designated agents; and the Entity's designated professional
credentials verification organization (collectively referred to as ?Agents?), to investigate information, which
includes both oral and written statements, records, and documents, concerning my application for Participation. I
agree to allow the Entity and/or its Agent(s) to inspect all records and documents relating to such an investigation.

Third-Party Sources to Release Information Concerning Application for Participation: I authorize any third
party, including, but not limited to, individuals, agencies, medical groups responsible for credentials verification,
corporations, companies, employers, former employers, hospitals, health plans, health maintenance
organizations, managed care organizations, law enforcement or licensing agencies, insurance companies,
educational and other institutions, military services, medical credentialing and accreditation agencies, professional
medical societies, the Federation of State Medical Boards, the National Practitioner Data Bank, and the Health
Care Integrity and Protection Data Bank, to release to the Entity and/or its Agent(s), information, including
otherwise privileged or confidential information, concerning my professional qualifications, credentials, clinical
competence, quality assurance and utilization data, character, mental condition, physical condition, alcohol or
chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing
on my qualifications for Participation in, or with, the Entity. I authorize my current and past professional liability
carrier(s) to release my history of claims that have been made and/or are currently pending against me. I
specifically waive written notice from any entities and individuals who provide information based upon this
Authorization, Attestation and Release.


Release and Exchange of Disciplinary Information: I hereby further authorize any third party at which I
currently have Participation or had Participation and/or each third party?s agents to release ?Disciplinary
Information,? as defined below, to the Entity and/or its Agent(s). I hereby further authorize the Agent(s) to release
Disciplinary Information about any disciplinary action taken against me to its participating Entities at which I have
Participation, and as may be otherwise required by law. As used herein, ?Disciplinary Information? means
information concerning: (i) any action taken by such health care organizations, their administrators, or their
medical or other committees to revoke, deny, suspend, restrict, or condition my Participation or impose a
corrective action plan; (ii) any other disciplinary action involving me, including, but not limited to, discipline in the
employment context; or (iii) my resignation prior to the conclusion of any disciplinary proceedings or prior to the
commencement of formal charges, but after I have knowledge that such formal charges were being (or are being)
contemplated and/or were (or are) in preparation.




Provider Initials: Date:




MC-5
DEC 05 Page 14 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Releases

Release from Liability. I release from all liability and hold harmless any Entity, its Agent(s), and any other third
party for their acts performed in good faith and without malice unless such acts are due to the gross negligence or
willful misconduct of the Entity, its Agent(s), or other third party in connection with the gathering, release and
exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release.
I further agree not to sue any Entity, any Agent(s), or any other third party for their acts, defamation or any other
claims based on statements made in good faith and without malice or misconduct of such Entity, Agent(s) or third
party in connection with the credentialing process. This release shall be in addition to, and in no way shall limit,
any other applicable immunities provided by law for peer review and credentialing activities.

In this Authorization, Attestation and Release, all references to the Entity, its Agent(s), and/or other third party
include their respective employees, directors, officers, advisors, counsel, and agents. The Entity or any of its
affiliates or agents retains the right to allow access to the application information for purposes of a credentialing
audit to customers and/or their auditors to the extent required in connection with an audit of the credentialing
processes and provided that the customer and/or their auditor executes an appropriate confidentiality agreement.
I understand and agree that this Authorization, Attestation and Release is irrevocable for any period during which
I am an applicant for Participation at an Entity, a member of an Entity's medical or health care staff, or a
participating provider of an Entity. I agree to execute another form of consent if law or regulation limits the
application of this irrevocable authorization. I understand that my failure to promptly provide another consent may
be grounds for termination or discipline by the Entity in accordance with the applicable bylaws, rules, and
regulations, and requirements of the Entity, or grounds for my termination of Participation at or with the Entity. I
agree that information obtained in accordance with the provisions of this Authorization, Attestation and Release is
not and will not be a violation of my privacy.


Attestation

I certify that all information provided by me in my application is true, correct, and complete to the best of my
knowledge and belief, and that I will notify the Entity and/or its Agent(s) within 10 days of any material changes to
the information I have provided in my application or authorized to be released pursuant to the credentialing
process. I understand that corrections to the application are permitted at any time prior to a determination of
Participation by the Entity, and must be submitted on-line or in writing, and must be dated and signed by me (may
be a written or an electronic signature). I understand and agree that the information provided on this application
may be shared with appropriate State and federal agencies.

I understand and agree that any material misstatement or omission in the application may constitute grounds for
withdrawal of the application from consideration; denial or revocation of Participation; and/or immediate
suspension or termination of Participation. This action may be disclosed to the Entity and/or its Agent(s). I further
understand and agree that submitting false, misleading or incomplete information may result in the imposition of
administrative, civil and/or criminal sanctions, in accordance with State and federal law.

I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release. I
understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as
effective as the original.



Name (Print or Type)


Social Security Number



Signature


Date