Physician Assistant

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Thank you for your interest in Horizon NJ Health Manage Care Network. Enclosed is an application and
information for your review and competition. Please use this check list as a guide during this process.

Provider Name: _____________________________________________ Applying as: ?PCP and/or ?Specialist
County: ________________________________ Provider participates with Horizon BCBS of NJ? ? Yes or ? No
Office Manager/Contact: __________________________________ Telephone:___________________________

The following documentation is required to submit an application:

? Fully completed NJ Universal Application (Please review question 26 carefully. If you answer YES, no
documentation is needed) OR CAQH #_________________________________________

? 2 Signed Agreements ? Please DO NOT insert an effective date or alter the agreements. The agreements
will be countersigned and dated with the effective date upon approval. An executed copy will be returned to
you by mail.

? W-9 form

? Copy of Board Certification or proof of Board Eligibility (i.e. NCCPA, ANA, NAPNAP, ACNM).

? Current copy of State Registered Nurse?s License, Physician Assistant License, Midwifery License
and/or EN Practitioner?s License.**

? Hospital and/or Birthing Center Privilege Letter(s) ? Must have a delineation of privileges; be dated within
6 months of request date; stating the provider has active privileges and is in good standing. This item is not
required for Physician Assistant applicants.

? Must have a Statement of Collaboration from managing physician and management plan of care.

? Curriculum Vitae ? please fill in requested information in addition to attaching CV

? Copy of Malpractice Insurance Certificate face sheet policy showing policy period and liability limits.**

? Documentation of continuing Medical Education Credits.

? Special Needs Survey

? American with Disabilities Act (ADA) Provider Survey (one per location)

? For Affordable Care Act eligible providers, please submit a Self or Group ACA Attestation Form



** In order to avoid unnecessary delays please make sure all documentation is dated within the last six
months and is not within 3 month of expiration.



Upon credentialing, the physician/provider is required to attend a brief orientation session with the Professional
Relations Representative assigned to your territory.



THE CREDENTIALING COMMITTEE MEETS ON A MONTHLY BASIS; THEREFORE, ONCE WE RECEIVE
YOUR APPLICATION FOR PROCESSING PLEASE ALLOW 8-10 WEEKS.

Thank you very much for your attention to this matter. We look forward to having your office as part of our select
physician network. Please send applications to:


Horizon NJ Health
210 Silvia Street
West Trenton, NJ 08628



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







Physician Assistant

Statement of Collaboration










This statement certifies that:





___________________________________________is the Managing Physician of

(Managing Physician)



Record who works in collaboration with ________________________________,

(PA)


who practices as a ________________________________ and coordinates medical

(Specialty)


services provided to Horizon NJ Health members, as stated in the American Academy of



Physician Assistant?s Standards of Practice. Our standard of practice/policies are




attached hereto or are available for review during site visit to our facility.







________________________________________

Managing Physician Signature





________________________________________

Managing Physician name (printed)





Date: ___________________________________





Give form to the
requester. Do not
send to the IRS.

Form W-9 Request for Taxpayer
Identification Number and Certification(Rev. January 2003)

Department of the Treasury
Internal Revenue Service

Name

List account number(s) here (optional)

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

P
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S
ee

S
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2.

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN).
However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on
page 3. For other entities, it is your employer identification number (EIN). If you do not have a number,
see How to get a TIN on page 3.

Social security number

??
or

Requester?s name and address (optional)

Employer identification numberNote: If the account is in more than one name, see the chart on page 4 for guidelines on whose number
to enter. ?

Certification

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and

2.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 4.)

Sign
Here

Signature of
U.S. person ? Date ?

Purpose of Form

Form W-9 (Rev. 1-2003)

Part I

Part II

Business name, if different from above

Cat. No. 10231X

Check appropriate box:

Under penalties of perjury, I certify that:

U.S. person. Use Form W-9 only if you are a U.S. person
(including a resident alien), to provide your correct TIN to the
person requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued),

2. Certify that you are not subject to backup withholding,
or

3. Claim exemption from backup withholding if you are a
U.S. exempt payee.

Foreign person. If you are a foreign person, use the
appropriate Form W-8 (see Pub. 515, Withholding of Tax on
Nonresident Aliens and Foreign Entities).

3. I am a U.S. person (including a U.S. resident alien).

A person who is required to file an information return with
the IRS, must obtain your correct taxpayer identification
number (TIN) to report, for example, income paid to you, real
estate transactions, mortgage interest you paid, acquisition
or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.

Individual/
Sole proprietor Corporation Partnership Other ?

Exempt from backup
withholding

Note: If a requester gives you a form other than Form W-9
to request your TIN, you must use the requester?s form if it is
substantially similar to this Form W-9.

Nonresident alien who becomes a resident alien.
Generally, only a nonresident alien individual may use the
terms of a tax treaty to reduce or eliminate U.S. tax on
certain types of income. However, most tax treaties contain a
provision known as a ?saving clause.? Exceptions specified
in the saving clause may permit an exemption from tax to
continue for certain types of income even after the recipient
has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an
exception contained in the saving clause of a tax treaty to
claim an exemption from U.S. tax on certain types of income,
you must attach a statement that specifies the following five
items:

1. The treaty country. Generally, this must be the same
treaty under which you claimed exemption from tax as a
nonresident alien.

2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that

contains the saving clause and its exceptions.
4. The type and amount of income that qualifies for the

exemption from tax.
5. Sufficient facts to justify the exemption from tax under

the terms of the treaty article.



Form W-9 (Rev. 1-2003) Page 2

Sole proprietor. Enter your individual name as shown on
your social security card on the ?Name? line. You may enter
your business, trade, or ?doing business as (DBA)? name on
the ?Business name? line.

Other entities. Enter your business name as shown on
required Federal tax documents on the ?Name? line. This
name should match the name shown on the charter or other
legal document creating the entity. You may enter any
business, trade, or DBA name on the ?Business name? line.

If the account is in joint names, list first, and then circle,
the name of the person or entity whose number you entered
in Part I of the form.

Limited liability company (LLC). If you are a single-member
LLC (including a foreign LLC with a domestic owner) that is
disregarded as an entity separate from its owner under
Treasury regulations section 301.7701-3, enter the owner?s
name on the ?Name? line. Enter the LLC?s name on the
?Business name? line.

Specific Instructions

Name

Exempt From Backup Withholding

Generally, individuals (including sole proprietors) are not
exempt from backup withholding. Corporations are exempt
from backup withholding for certain payments, such as
interest and dividends.

5. You do not certify to the requester that you are not
subject to backup withholding under 4 above (for reportable
interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
Instructions for the Requester of Form W-9.

Civil penalty for false information with respect to
withholding. If you make a false statement with no
reasonable basis that results in no backup withholding, you
are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully
falsifying certifications or affirmations may subject you to
criminal penalties including fines and/or imprisonment.

Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN
to a requester, you are subject to a penalty of $50 for each
such failure unless your failure is due to reasonable cause
and not to willful neglect.

Misuse of TINs. If the requester discloses or uses TINs in
violation of Federal law, the requester may be subject to civil
and criminal penalties.

If you are an individual, you must generally enter the name
shown on your social security card. However, if you have
changed your last name, for instance, due to marriage
without informing the Social Security Administration of the
name change, enter your first name, the last name shown on
your social security card, and your new last name.

Exempt payees. Backup withholding is not required on any
payments made to the following payees:

1. An organization exempt from tax under section 501(a),
any IRA, or a custodial account under section 403(b)(7) if the
account satisfies the requirements of section 401(f)(2);

2. The United States or any of its agencies or
instrumentalities;

3. A state, the District of Columbia, a possession of the
United States, or any of their political subdivisions or
instrumentalities;

4. A foreign government or any of its political subdivisions,
agencies, or instrumentalities; or

5. An international organization or any of its agencies or
instrumentalities.

Other payees that may be exempt from backup
withholding include:

6. A corporation;
7. A foreign central bank of issue;
8. A dealer in securities or commodities required to register

in the United States, the District of Columbia, or a
possession of the United States;

If you are exempt, enter your name as described above and
check the appropriate box for your status, then check the
?Exempt from backup withholding? box in the line following
the business name, sign and date the form.

4. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
dividends on your tax return (for reportable interest and
dividends only), or

3. The IRS tells the requester that you furnished an
incorrect TIN, or

2. You do not certify your TIN when required (see the Part
II instructions on page 4 for details), or

You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make
the proper certifications, and report all your taxable interest
and dividends on your tax return.

1. You do not furnish your TIN to the requester, or

What is backup withholding? Persons making certain
payments to you must under certain conditions withhold and
pay to the IRS 30% of such payments (29% after December
31, 2003; 28% after December 31, 2005). This is called
?backup withholding.? Payments that may be subject to
backup withholding include interest, dividends, broker and
barter exchange transactions, rents, royalties, nonemployee
pay, and certain payments from fishing boat operators. Real
estate transactions are not subject to backup withholding.

Payments you receive will be subject to backup
withholding if:

If you are a nonresident alien or a foreign entity not
subject to backup withholding, give the requester the
appropriate completed Form W-8.

Example. Article 20 of the U.S.-China income tax treaty
allows an exemption from tax for scholarship income
received by a Chinese student temporarily present in the
United States. Under U.S. law, this student will become a
resident alien for tax purposes if his or her stay in the United
States exceeds 5 calendar years. However, paragraph 2 of
the first Protocol to the U.S.-China treaty (dated April 30,
1984) allows the provisions of Article 20 to continue to apply
even after the Chinese student becomes a resident alien of
the United States. A Chinese student who qualifies for this
exception (under paragraph 2 of the first protocol) and is
relying on this exception to claim an exemption from tax on
his or her scholarship or fellowship income would attach to
Form W-9 a statement that includes the information
described above to support that exemption.

Note: You are requested to check the appropr iate box for
your status (individual/sole propr ietor, corporation, etc. ).

Note: If you are exempt from backup withholding, you should
still complete this form to avoid possible erroneous backup
withholding.



Form W-9 (Rev. 1-2003) Page 3

Part I. Taxpayer Identification
Number (TIN)
Enter your TIN in the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an
SSN, your TIN is your IRS individual taxpayer identification
number (ITIN). Enter it in the social security number box. If
you do not have an ITIN, see How to get a TIN below.

How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS-5,
Application for a Social Security Card, from your local Social
Security Administration office or get this form on-line at
www.ssa.gov/online/ss5.html. You may also get this form
by calling 1-800-772-1213. Use Form W-7, Application for
IRS Individual Taxpayer Identification Number, to apply for an
ITIN, or Form SS-4, Application for Employer Identification
Number, to apply for an EIN. You can get Forms W-7 and
SS-4 from the IRS by calling 1-800-TAX-FORM
(1-800-829-3676) or from the IRS Web Site at www.irs.gov.

If you are asked to complete Form W-9 but do not have a
TIN, write ?Applied For? in the space for the TIN, sign and
date the form, and give it to the requester. For interest and
dividend payments, and certain payments made with respect
to readily tradable instruments, generally you will have 60
days to get a TIN and give it to the requester before you are
subject to backup withholding on payments. The 60-day rule
does not apply to other types of payments. You will be
subject to backup withholding on all such payments until you
provide your TIN to the requester.

If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that
you use your SSN.

If you are a single-owner LLC that is disregarded as an
entity separate from its owner (see Limited liability
company (LLC) on page 2), enter your SSN (or EIN, if you
have one). If the LLC is a corporation, partnership, etc., enter
the entity?s EIN.
Note: See the chart on page 4 for further clar ification of
name and TIN combinations.

Note: Writing ?Applied For? means that you have already
applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign
owner must use the appropr iate Form W-8.

9. A futures commission merchant registered with the
Commodity Futures Trading Commission;

10. A real estate investment trust;
11. An entity registered at all times during the tax year

under the Investment Company Act of 1940;
12. A common trust fund operated by a bank under

section 584(a);
13. A financial institution;
14. A middleman known in the investment community as a

nominee or custodian; or
15. A trust exempt from tax under section 664 or

described in section 4947.

THEN the payment is exempt
for . . .

If the payment is for . . .

All exempt recipients except
for 9

Interest and dividend payments

Exempt recipients 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker

Broker transactions

Exempt recipients 1 through 5Barter exchange transactions
and patronage dividends

Generally, exempt recipients
1 through 7 2

Payments over $600 required
to be reported and direct
sales over $5,000 1

1 See Form 1099-MISC, Miscellaneous Income, and its instructions.
2 However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 6045(f), even if the attorney is a
corporation) and reportable on Form 1099-MISC are not exempt from backup
withholding: medical and health care payments, attorneys? fees; and payments
for services paid by a Federal executive agency.

The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt recipients listed above, 1 through 15.



Form W-9 (Rev. 1-2003) Page 4



What Name and Number To Give the
Requester

Give name and SSN of:For this type of account:

The individual1. Individual

The actual owner of the account
or, if combined funds, the first
individual on the account 1

2. Two or more individuals (joint
account)

The minor 23. Custodian account of a minor
(Uniform Gift to Minors Act)

The grantor-trustee 14. a. The usual revocable
savings trust (grantor is
also trustee)

1. Interest, dividend, and barter exchange accounts
opened before 1984 and broker accounts considered
active during 1983. You must give your correct TIN, but you
do not have to sign the certification.

The actual owner 1b. So-called trust account
that is not a legal or valid
trust under state law2. Interest, dividend, broker, and barter exchange

accounts opened after 1983 and broker accounts
considered inactive during 1983. You must sign the
certification or backup withholding will apply. If you are
subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2
in the certification before signing the form.

The owner 35. Sole proprietorship or
single-owner LLC

Give name and EIN of:For this type of account:

3. Real estate transactions. You must sign the
certification. You may cross out item 2 of the certification.

A valid trust, estate, or
pension trust

6.

Legal entity 4

4. Other payments. You must give your correct TIN, but
you do not have to sign the certification unless you have
been notified that you have previously given an incorrect TIN.
?Other payments? include payments made in the course of
the requester?s trade or business for rents, royalties, goods
(other than bills for merchandise), medical and health care
services (including payments to corporations), payments to a
nonemployee for services, payments to certain fishing boat
crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).

The corporationCorporate or LLC electing
corporate status on Form
8832

7.

The organizationAssociation, club, religious,
charitable, educational, or
other tax-exempt organization

8.

5. Mortgage interest paid by you, acquisition or
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529),
IRA or Archer MSA contributions or distributions, and
pension distributions. You must give your correct TIN, but
you do not have to sign the certification.

The partnershipPartnership or multi-member
LLC

9.

The broker or nomineeA broker or registered
nominee

10.

The public entityAccount with the Department
of Agriculture in the name of
a public entity (such as a
state or local government,
school district, or prison) that
receives agricultural program
payments

11.

Privacy Act Notice

1 List first and circle the name of the person whose number you furnish. If only
one person on a joint account has an SSN, that person?s number must be
furnished.
2 Circle the minor?s name and furnish the minor?s SSN.
3 You must show your individual name, but you may also enter your
business or ?DBA? name. You may use either your SSN or EIN (if you have
one).
4 List first and circle the name of the legal trust, estate, or pension trust. (Do
not furnish the TIN of the personal representative or trustee unless the legal
entity itself is not designated in the account title.)

Note: If no name is circled when more than one name is
listed, the number will be considered to be that of the first
name listed.

Sole proprietorship or
single-owner LLC

The owner 3

12.

Part II. Certification

For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt recipients, see
Exempt from backup withholding on page 2.

You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 30% of taxable
interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.

To establish to the withholding agent that you are a U.S.
person, or resident alien, sign Form W-9. You may be
requested to sign by the withholding agent even if items 1, 3,
and 5 below indicate otherwise.

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns
with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or
abandonment of secured property, cancellation of debt, or contributions you made to an IRA or Archer MSA. The IRS uses the
numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information
to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their
tax laws. We may also disclose this information to other countries under a tax treaty, or to Federal and state agencies to enforce
Federal nontax criminal laws and to combat terrorism.

Signature requirements. Complete the certification as
indicated in 1 through 5 below.







PPrrooffeessssiioonnaall RReellaattiioonnss
CCoonnffiiddeennttiiaall MMaallpprraaccttiiccee IInnffoorrmmaattiioonn





PPrroovviiddeerr NNaammee:: ____________________________________________________


DDaattee ooff OOccccuurrrreennccee:: ________________________________________________


MMaallpprraaccttiiccee CCaarrrriieerr:: _________________________________________________


CCoommppllaaiinntt//AAlllleeggaattiioonn:: _______________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________



RRoollee iinn tthhee eevveenntt:: __________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________


YYoouurr oowwnn ooppiinniioonn ooff wwhhaatt ooccccuurrrreedd:: ____________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________


CCuurrrreenntt SSttaattuuss ooff ssuuiitt:: ______________________________________________


SSiiggnnaattuurree:: _____________________________ DDaattee:: ________________






PROVIDER NETWORK SPECIAL NEEDS SURVEY
(Please complete all blank fields)



Name: Specialty:

Medicaid #: NPI#:



Address:

City: State: Zip:

Telephone: Fax:




(Please check Yes or No and provide explanation if necessary)


1. Do you have formal training and/or experience treating adults/children with special needs including persons with physical,
mental, substance abuse or developmental disabilities? Yes No

DDD? Yes No

Blind? Yes No

Deaf? Yes No

Non-Ambulatory? Yes No

Non-Verbal? Yes No

HIV/Aids? Yes No

Aged? Yes No



If ?Yes?, please explain:



____________________________________________________________________________________________________________




2. Do you have a specific area of interest or expertise in any medical or behavioral conditions / disorders?
Yes No

If ?Yes?, please explain:







Physician Signature or Designee: Date:


SERVICE ADDRESS

PHYSICIAN INFORMATION TAX ID#:______________






1
ADA Provider Survey Information in brackets [thus]

from New Jersey Protection & Advocacy, Inc.


Americans with Disabilities ACT (ADA) Provider Survey



Physician Name _____________________________NPI:______________________________

Group Name _________________________________________________________________

Address* __________________________________Office Phone________________________

__________________________________Office Fax__________________________

__________________________________


*(Complete a separate survey form for each office location.)


Part I. (This section to be answered by all providers):

1. Number of staff members (includes all medical professionals, members or partners of the

professional association, technicians and support staff), employed at this office:
______________.


2. Year when the building in which provider?s office is located was constructed: ___________.

3. Floor(s) of building on which provider?s office is located: ___________.

4. Please answer following questions regarding architectural accessibility to provider?s office:


a) Is handicap parking available: Yes No

[Parking for disabled persons must be located on the shortest accessible route of travel
from adjacent parking to an accessible building entrance. In parking facilities that do not
serve a particular building accessible parking spaces should be located on the shortest
route to an accessible pedestrian entrance to the parking facility. When buildings have
multiple accessible entrances with adjacent parking, accessible parking spaces should
be dispersed and located near the accessible entrances which should be as level as
possible with surface slopes not exceeding ? inch per foot in all directions. Each
parking space should be marked with an R708 sign from the Manual of Uniform Traffic
Control Devices displaying the International Symbol of Accessibility. The bottom edge of
the sign shall be mounted approximately 60 inches above the parking lot surface. See
sample attached.]




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ADA Provider Survey Information in brackets [thus]

from New Jersey Protection & Advocacy, Inc.

[Standard accessible spaces must have an access aisle at least 5 feet wide, and at least
one of every eight accessible spaces must be van-accessible. Spaces that provide van
access must have an access aisle at least 8 feet wide. The number of spaces for
disabled persons that must be provided is determined by the total number of parking
spaces available. For example:
1 ? 25 spaces 1 Accessible Space
25 ? 50 spaces 2 Accessible Spaces
51 ? 75 spaces 3 Accessible Spaces
76 ? 100 spaces 4 Accessible Spaces


[See ADAAG, 4.6]


b) Is path of travel from the parking lot to the Yes No
entrance of the building in which the provider?s
office located barrier-free?


[The path of travel should be continuous, barrier-free and slip-resistant. Curb ramps
(also known as curb cuts) are required wherever an accessible route crosses a curb. It is
important that transitions to curb ramps be flush. Lips at the bottom of ramps impede
the momentum needed to propel a wheelchair up a slope. The running slope of a curb
ramp cannot exceed 1:12. The minimum clear width of a curb ramp is 36 inches. It is
also important that parked cars, lampposts, utility poles and other elements placed along
sidewalks not obstruct connecting accessible routes. See ADAAG, 4.7]


c) Is there street-level access or an accessible Yes No
ramp into the building in which the provider?s
office is located?


[Where the running slope of an accessible route is more than 5%, it is considered a ramp.
Slope and length determine a ramp?s usability. A maximum slope of 1:12 is
recommended, but the ?least possible? slope is encouraged. Slopes should be
consistent along the full length of the run. The minimum clear width for ramps is 36
inches and is measured between the leading edge of the handrails. Handrails with a
diameter of 1 ? to 1 ? inches are required on both sides for ramps with a rise of more
that 6 inches or a horizontal length of more than 72 inches. Covering ramps with a
canopy or roof is not required but should be considered to protect the ramp from
becoming wet or icy. Landings at the top and bottom must be at least 60 inches long for
maneuvering space. See ADAAG, 4.8]


d) If the provider?s office is not on the first floor, Yes No
is the office served by a working elevator
which is accessible by a wheelchair or

motorized scooter?


[The call buttons for the elevator should be no more that 42 inches high. The elevator
should have both visible and verbal indicators and the controls should have raised and
Braille lettering. See ADAAG, 4.10]




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ADA Provider Survey Information in brackets [thus]

from New Jersey Protection & Advocacy, Inc.

e) Are the provider?s office and other patient Yes No
areas accessible by wheelchair and
motorized scooter?

[A continuous minimum clear width of 36 inches is required for accessible routes. A
reduction to 32 inches is allowed for linear distances of no more that 24 inches, such as
a doorway. For a double door, at least one leaf must be 32 inches wide. The threshold of
a doorway must be ? inch or less, and if beveled, no more that ? inch high. The door
handle must be no higher than 48 inches and operable with a closed fist. U-shaped
handles are recommended].

[Registration and patient interview areas with built-in counters should be 28 ? 34 inches
high with knee spaces at least 27 inches high, 30 inches wide, and 19 inches deep. If this
is not readily achievable, alternative measures such as a table or clipboard should be
provided. See ADAAG, 4.2]


f) Are examination rooms accessible by Yes No
wheelchair and motorized scooters?


[Standard equipment is often difficult for people with disabilities to use. For example,
standard height examining tables and traditional scales cannot be used by many people
with disabilities. An adjustable height examining table is a good solution as is a portable
low table. Additionally, allowing some tests to be performed from a wheelchair is also
acceptable.]


g) Are the office?s restrooms accessible Yes No
by wheelchair and motorized scooter?


[Signs to the restroom should be mounted on the wall. The doorway should be 32 inches
clear with accessible handle 48 inches from the ground or less. The doors should be
easily opened and the entry should provide 36 inches of clear width for forward
movement and a 5-foot T-shaped clear space for turns. A minimum of 48 inches clear of
the door swing is needed between the two doors of an entry vestibule. The past two
fixtures should be 36 inches clear. The stall door should be operable with a closed fist.
The toilet seat should be 17 ? 19 inches high with grab bars on the wall near and behind
the toilet. The sink should have a 30 inch wide by 48 inch deep clear space in front with a
rim no higher than 34 inches and 29 inches from the floor to the bottom of the sink. The
faucets should be operable with a closed fist and the soap dispenser should be within a
reachable range. See ADAAG, 4.15 ? 4.26.]

[Please also note: Issues of accessibility also include access for people with sensory
impairments. It is customary to offer to orient a person with a vision impairment to his or
her surroundings. If the person accepts the offer of assistance, a staff person should
offer his or her arm and guide the person alerting him to obstacles along the way.

Methods of making printed material and forms accessible to people with vision
impairments must be considered such as offering large print material, good lighting near
the office, and inexpensive magnifier, or audio cassette materials. For people with
hearing or speech impairments, short communication in writing is acceptable. Please



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ADA Provider Survey Information in brackets [thus]

from New Jersey Protection & Advocacy, Inc.

allow time to foster effective communication, if necessary. Providing a sign language
interpreter may be necessary when discussing complex matters.]



If you answered ?yes? to every question 4a through 4g above, please skip the remaining
questions and sign the attached certification.

If you answered ?no? to any question 4a through 4g, and:


a) The building in which the office is located was built before January 1992 and
structural alterations were made to the building after January 1992, please
answer the questions in Part II and sign certification.


b) The building in which the office is located was built before January 1992, no

alterations were made after that date and 15 or more staff are employed at
the office, please answer questions in Part III and sign certification.


c) The building in which the office is located was built before January 1992, no

alterations were made to it after that date and fewer than 15 staff are
employed at the provider?s office, please answer the question in Part IV and sign
certification.




Part II- Building constructed before 1992 with structural alterations made to building
after that date:

5. What alterations were made to the building? ______________________________________


____________________________________________________________________________


6. If the altered portions of the building affected the usability of the facility, are the altered

portions of the office readily accessible to and usable by mobility?impaired and disabled
individuals?

Yes No


7. If the answer to question 6 is ?no?, explain: _______________________________________

____________________________________________________________________________

Part III ? Building constructed before January 1992 ? no alterations made to the building
after that date?provider has 15 or more staff employed at that location:

8. Does the provider or group have an alternate accessible location where services can be

provided to mobility impaired or disabled individuals? Yes No





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ADA Provider Survey Information in brackets [thus]

from New Jersey Protection & Advocacy, Inc.

9. If the answer to question 8 is ?yes?, please describe the facility, including its location and
distance from the provider?s office.


_________________________________________________________________________


_________________________________________________________________________


10. If the answer to question 8 is ?no?, will the provider accommodate mobility impaired and

disabled individuals through home visits? Yes No



Part IV ? Building constructed before January 1992?no alterations made to building after
that date?provider has fewer than 15 staff employed at that location.

11. If you determine after conferring with a mobility-impaired or disabled individual, that you are

unable to see the individual in your office without making significant architectural alterations
to the building or office, are you, the provider, willing to see the patient at a mutually
acceptable and appropriate accessible location?
Yes No


New Jersey Handicapped Parking Laws






















PENALTY
$100 1st OFFENSE


SUBSEQUENT

OFFENSES
$100 MIN. AND/OR

UP TO 90 DAYS
COMMUNITY SERIVCE

TOW-AWAY ZONE



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ADA Provider Survey Information in brackets [thus]

from New Jersey Protection & Advocacy, Inc.

THE INDIVIDUAL COMPLETING THIS FORM MUST SIGN THE CERTIFICATION




CERTIFICATION OF ADA COMPLIANCE


Statement I

I hereby certify that I have reviewed the Americans with Disabilities Act (ADA), requirements
which are set out on the attached sheet, that I have answered the above questions truthfully and
the to best of my knowledge and that this (office/group practice) as well as the building in which
it is located, meets the requirements of the ADA.


______________________________ _____________________________
Provider Name Provider Group Name



________________________________ _____________________________
Signature Date




-OR-



Statement II

I hereby certify that I have reviewed the Americans with Disabilities Act (ADA), requirements
which are set out on the attached sheet, that I have answered the above questions truthfully and
the to best of my knowledge and that this (office/group practice) has 15 staff members or less.
Therefore, the ADA requirements do not apply.

______________________________ _____________________________
Provider Name Provider Group Name



________________________________ _____________________________
Signature Date





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