Application for EyeCare of WI Checklist
Submit ALL of the following forms for consideration:
- Completed Application form (Sections I-IV below)
OR Current CAQH Application form.
- All applicable documents listed under Section V of this application
Return all documents:
- By email:
- By fax to: 414-727-7801
- By mail: Eyecare of WI, 740 N. Plankinton Ave, #730B,
Milwaukee, WI 53203
INDEPENDENT ASSOCIATION OF OPTOMETRISTS, S.C.
Application Form
I. Personal Information:
Name Degree Date of Birth //
Home Address Social Security Number//
City_ County State Zip
Home Phone -- Cell Phone--
II. Business Information:
Business Name, Address and Billing Name if different:
City County State Zip
Business Telephone Number :-- Business Fax Number :--
E-mail Address:
Tax ID. #Medicare Provider #
UPIN#Medicaid Provider #
O.D. NPI# Billing Office NPI #
CAQH # Taxonomy #
Do you bill with your Tax ID, Social Security, or NPI number? Tax ID Soc. Sec. NPI
Primary Office Address (if different from above business address):
How many hours per week are you in your primary office:
Secondary Office address(es) Hours per week practiced there
Please list other optometrists who practice at each location (both full and part time):
NameState License #Hours & Location
Work History Please list your work history for the past five years. A current Curriculum Vitae or Resume is acceptable in place of a work history.
III. Educational, Licensing, and Professional Information
Educational Information:
College/University AddressDegreeYear
Graduate Internship, Residency, or Fellowship
College/UniversityAddressSpecialty DegreeYear
Please list any Academic Appointments:
Licensing Information:
State(s) in which you are licensed to practice optometry and License(s) number(s):
State License Number Expiration Date
If you are DPA licensed, list State, License number and Expiration date:
If you are TPA licensed, list State, License number and Expiration date:
If you are DEA licensed, please list your DEA number
and check all schedules you currently hold: I II II N III III N IVV
Board Certification (if applicable): Certification Date (if applicable):
Professional Information:
CurrentHospital Affiliation(s):
Primary:
Secondary:
Please list your affiliations with other Health Care Provider groups, Entities or Organizations:
Please list current Professional affiliations, Memberships, Societies, etc.
Please list ALL professional liability insurance carriers for the past five years.
Indicate which is/are current
Do you have a majority ownership (over 50%) of the dispensing unit at your practice location(s)?
Y N
If "No", list the majority owner(s):
Do you or any of your staff speak a foreign language?Y N
If "Yes", please list the language(s) and the office(s) were this service is available:
Do you provide Primary Care (Refractive) services?Y N
If "No", what is your specialty?
Does your office provide emergency services to your patients?Y N
If "Yes", please describe:
Does your office provide access for the physically disabled? Y N
IV. Liability Background
1.)Is your professional liability insurance current and do coverage Y N
amounts meet state minimum requirements?
All "Yes" answers for questions 2 – 20 should be explained in writing on a separate sheet and attached to this form before returning it to Eye Care of Wisconsin Insurance, Inc.
2.) Have you been examined by a Specialty Board but failed to pass?YN
3.) Has your Board Certification (if applicable) been suspended or revoked,
or are such actions pending against you by any State?YN
4.) Have any disciplinary actions been initiated or are any pending against
you by any State Licensing Board?Y N
5.) Has your license to practice optometry or medicine in any State been denied,
limited, suspended, revoked or voluntarily relinquished?Y N
6.) Have you been suspended, sanctioned or otherwise restricted from
participating in any State, Private or Federal Health program (for example
Medicare, Medicaid or any Managed Care Organization)? YN
7.) Have you been the subject of an investigation by any Private, Federal or
State agency (including Professional Review Organizations) concerning
your participation in any Private, Federal or State Health ProgramY N
8.) Has your Federal DEA and/or State Controlled Substance Certificate been
voluntarily or involuntarily limited, suspended, revoked or relinquished
or are any proceedings of this nature currently pending?Y N
9.) Have you been convicted of a felony or misdemeanor or have any charges
pending other than traffic violations?Y N
10.)Has your professional liability insurance coverage been terminated by action
of an insurance company?Y N
11.)Have you been denied professional liability insurance coverage or rated
in a higher-than-average risk class for your professional specialty?Y N
12.)Have any professional liability suits, actions or claims alleging malpractice
been filed against you?Y N
13.) Have any professional liability suits, actions or claims been filed against you
that are currently pending?YN
14.) Have any judgments been made against you in professional liability cases
or claims, or have you entered into any settlements?YN
15.) Have your memberships or clinical privileges been involuntarily limited,
reduced, or relinquished or have your clinical privileges been terminated
by any other health care entity (i.e., hospital, HMO, PPO)?YN
16.) Have your applications for appointments or reappointments or your privileges
at any hospital or other health care facility been denied, reduced,
suspended or not renewed?Y N
17.) Have you involuntarily resigned from the medical staff of any health care
entity?Y N
18.) During your post graduate education, internship, residency, fellowship or
additional training were you disciplined, suspended, placed upon
probation, formally reprimanded or asked to resign?Y N
19.) Have you been denied membership or renewal thereof in any optometric
or medical society or been subjected to disciplinary proceedings in any
professional organizations?Y N
20.) Have you had or are you currently aware of having any physical, mental
or emotional conditions or chemical dependency/substance abuse
problems which may interfere with your ability to care for a patient in
any way with or without accommodations?Y N
V. Documents
You MUST include the following documentation with this application:
1)One Copy of your CurrentState License
2)One Copy of your DEA certificate, if Applicable
3)One Copy of your current TPA - DPA licenses, if not listed on your Current State License
4)Copy of current Certificate of Liability Insurance (cover sheet only)
5)Copy of CAQH confirmation with CAQH ID number for each provider
6)Ophthalmologists ONLY -One Copy of your proof of Fellowship participation
7)Ophthalmologists ONLY -One Copy of your current Board Certificate
Attestation Statement
I ACKNOWLEDGE AND AGREE THAT:
1.)Privileges to participate as a Provider with the Plan(s) is NOT a Right; and
2.)By applying for privileges with the Plan(s), I am agreeing to comply with the Terms and conditions of the
Provider Agreement, whether signed by me or not, pursuant to which I am rendering services to the Plan
Members either as a Subcontractor or Covering Provider.
3.)I acknowledge that my Liability Insurance Coverage is current and my amounts of Coverage meet the
minimum State Requirements.
I UNDERSTAND THAT:
A.)Any misrepresentation , misstatement or omission of a relevant fact in connection with this application may result in denial
of my application or termination of my participation in Eye Care of Wisconsin Insurance, Inc.,
B)It is my responsibility to promptly advice Eye Care of Wisconsin Insurance, Inc. of any changes or additions to the information contained in this document
C)All information contained in the document or its attachments is subject to Eye Care of Wisconsin Insurance, Inc.'s investigation and review
D)This is anApplication, Credentialing, and or Re-Credentialing form only and my submission does not automatically result in continued participation with Eye Care of Wisconsin Insurance, Inc.
The National Practitioner Data Bank will be queried during the Re-Credentialing process. If your application is rejected for reasons relating to professional conduct or professional competence, which includes but is not limited to misrepresenting, misstating or omitting a relevant fact in connection with your re-credentialing, the rejection may be reported to the National Practitioner Data Bank. During the credentialing and re-credentialing process Eye Care of Wisconsin Insurance, Inc. will obtain information from various outside primary sources (e.g. state licensing boards, National Practitioner Data Bank) to evaluate your application. You have the right to review any primary source information that Eye Care of Wisconsin collects during this process. However, this does not include references, recommendations or other information that is peer review protected. You will be notified of any information collected during the credentialing/recredentialing process that varied from the information that you provided. You have the right to correct any erroneous information.
I authorize Eye Care of Wisconsin Insurance, Inc. to consult with administrations and members of the medical staffs of hospitals or institutions with which I have been or am currently associated and with others, including past and present malpractice carriers who may have information bearing on my professional competence, character and ethical qualifications. I further consent to the inspection by representatives of Eye Care of Wisconsin Insurance, Inc. of all documents and practice locations that may be material to an evaluation of my professional competence, character and ethical qualifications.
I release from liability all representatives of Eye Care of Wisconsin Insurance, Inc. for their acts performed in good faith and without malice in connection with evaluating my application, credentialing, recredentialing and qualifications and I release from any liability any and all individuals and organizations who provide information to Eye Care of Wisconsin Insurance, Inc. in good faith and without malice concerning my professional competence, character and ethics and other qualifications for ineligibility. I consent to the release of and exchange of information relating to any disciplinary action, suspension or curtailment of optometric privileges to Eye Care of Wisconsin Insurance, Inc. and I authorize the medical societies of which I am a member to turn over to the representatives of Eye Care of Wisconsin Insurance, Inc. a copy of my application for membership and related documents.
If I am accepted, credentialed, and or recredentialed for participation in Eye Care of Wisconsin Insurance, Inc. I consent to Eye Care of Wisconsin Insurance, Inc., inspection of my patient records as necessary for its peer utilization review purposes and agree to be bound by Eye Care of Wisconsin Insurance, Inc.'s participation agreement, credentialing plan and provider manual.
I CERTIFY that I have answered the above application questions truthfully and I understand that as a condition to making this application any misrepresentation or misstatement in or by omission of any of these answers whether intentionally or not shall constitute grounds for rejection of my request for continued participation. I certify that this application is complete to the full extent of my knowledge and any unanswered areas have been explained in full on an attached sheet.
Signature of Provider Date
(typed signature will serve as a acceptance)
______
For Internal Use Only Credential recommendation:Accept Defer RejectDate:
Board of DirectorsAccept Defer RejectDate:
President's Signature Date
1
App/ReCred. Form 4/8/14 740 North Plankinton Avenue
Milwaukee, WI 53203
414-351-3030 or 1-800-373-6370, FAX 414-351-3603