REQUEST FOR PROVIDER APPLICATION

To request a credentialing application and provider status with GEMCare, please complete this form and return it to: Managed Care Systems, LP, QM/Credentialing Department, 4550 California Ave., Suite 500, Bakersfield, CA 93309 or fax it to (661) 716-9156.

Attach copies of the following documents:

 Curriculum Vitae or Resume  State Medical License(s)

 Work History  DEA

 Board Certification (if applicable)  Malpractice insurance face sheet

Please complete and sign this form:

______

Name (as it appears on your medical license) Primary Specialty Other Specialty

Primary Office Address with City, State and ZIP

Primary Telephone No. Primary Fax No.

2nd Office Address with City, State and Zip

2nd Telephone No. 2nd Fax No.

E-mail address:

Are you currently in practice with an established GEMCare provider?  Yes  No

If yes, what is the provider’s name and specialty?

In what specialties are you Board Certified or Board Eligible? (Pease specify whether certified or eligible.)

 Certified  Eligible

Specialty 1

 Certified  Eligible

Specialty 2

Tax I.D. Number Social Security Number Date of Birth

Name of Office Manager Languages Spoken other than English

Medical/Professional School(s) Attended Year of Graduation

Please list all Hospitals and Ambulatory Surgery Centers where you currently have privileges, starting with primary facility first:

1)

2)

3)

4)

5)

6)

Please detail any special skills, expertise or training that goes beyond that normally possessed by others in your specialty:

How many new patients is your office able to accommodate?

Printed or Typed Name

Provider Signature Date

GOLDEN EMPIRE MANAGED CARE, INC.

PROFESSIONAL WORK HISTORY

List chronologically all professional work history and/or employment since your medical school graduation. List your most current position first, and go in reverse chronological order. Explain any gaps in time/chronology on a separate sheet.

Printed Name

Provider Signature Date

APPLICATION AGREEMENT

DECLARATION ATTESTATION RELEASE

I declare under penalty of perjury under the laws of the State of California, that all statements, answers and information contained in the application are true, correct, and complete. I understand that falsification, misrepresentation or omission of any fact(s) will be sufficient cause for denial of this application and/or subsequent termination of any participating privileges granted upon the basis of this application. I agree to inform Golden Empire Managed Care, Inc. (GEMCare) in writing within fifteen (15) days, of any changes in the information provided and the answers to questions on the application as a result of new information or developments subsequent to my signing of the application.

I understand and agree that acceptance of this application does not constitute approval or acceptance of participating status in GEMCare, and grants me no rights or privileges of participation until such time as I receive written notice of participating status. I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubt about such qualifications.

I understand that the information contained in this application will be used to evaluate my credentials according to the quality assessment standards of GEMCare. I hereby consent to the disclosure, inspection and copying of information and documents relating to my credentials, qualifications and performance (“credentialing information") for the purpose of evaluating this application regarding my professional training, experience, character, conduct and judgment, ethics, and ability to work with others. In this regard, the utmost care shall be taken to safeguard the privacy of patient records, and to protect peer review information from being further disclosed.

I do hereby grant to GEMCare, and its authorized agent(s), permission to gain access to, inspect and duplicate any and all information, records, summaries of records, statistical reports (including utilization profiles pertinent to my provision of medical services), credentialing and peer review information and reports relative to my professional qualification from any and all acute care facilities, skilled nursing facilities, outpatient center, and any other institution with which I am now or have been or will be affiliated, as well as any local county, state and federal medical trade association. I further authorize GEMCare to query accrediting or private agencies or association organizations, medical societies, or governmental entities including licensing agencies and the National Practitioner Data Bank.

I hereby release GEMCare, its shareholders, directors, officers, agents, employees, contracting health plans and independent contractors from any and all liability and expenses which are directly or indirectly incurred by GEMCare as a result of the described inspection, duplication or release of information.

I further agree that a copy of this document will serve as a duplicate original.

Printed Name

Provider Signature Date

F:Credentialing/GEMCare/Pre-app – GEMCare – Updated 07/15/09

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