PRACTITIONER CONTRACT APPLICATION

Contract Application Instructions

1)  A W-9 form is required to identify the contracting entity before contract issuance. W-9 must accompany Contract Application.

2)  Please return application electronically as a Microsoft Word document (PDF AND FAXED COPIES WILL NOT BE ACCEPTED) to Roberto Fierro, Contract Development Manager at . W-9’s may be faxed to (619) 476-3836, if a PDF is not available. For questions regarding the application, please contact Maria Diaz, Administrative Assistant, at (619) 498-6560.

3)  If seeing patients under the age of 21 years, please apply to CCS and CHDP.

http://www.dhcs.ca.gov/services/ccs/Pages/ProviderEnroll.aspx

http://www.sdcounty.ca.gov/hhsa/programs/phs/child_health_disability_prevention_program/index.html

REQUESTED BY: Practitioner CHG

/

NOTE:

A. CONTACT INFORMATION

DATE: / CONTACT E-MAIL:
CONTACT NAME: / TITLE:
CONTACT PHONE #: / CONTACT FAX #:

B. PRACTITIONER/GROUP INFORMATION

ORGANIZATION NAME:
ORGANIZATION NPI #: / DBA:
OFFICE NAME:
(If different than organization name)
PRACTITIONER(S):
(If more than 1 practitioner and not credentialed, provide a roster with required data from Section C). / SPECIALTY: Oral Maxillofacial Surgery
SUBSPECIALTY:
TAX ID #: / NPI #: / Billing NPI # (required):
ADDRESS: / MEDI-CAL PROVIDER #:
PHONE #: / FAX #:
LANGUAGE(S) SPOKEN BY PRACTITIONER(S):
/ CALIFORNIA CHILDREN SERVICES (CCS) PANELED?
YES NO (If no, complete CCS application) N/A
CHILD HEALTH AND DISABILITY PREVENTION (CHDP) CERTIFIED? YES NO N/A
CONTRACT TYPE: PCP Specialist
Allied Health / CONTRACT: New Add
LINE(S) OF BUSINESS: Medi-Cal Cal MediConnect
(Must be CCS paneled if seeing patients under age 21)
ACCEPT STANDARD RATES? Yes / AGE RESTRICTIONS:
HOURS OF OPERATION:
(PCP must meet 32 hours per week minimum per location) / ACCEPT SAME DAY APPOINTMENTS? Yes No
SAN DIEGO COUNTY HOSPITAL PRIVILEGES (Please check all that apply): Not Applicable
Alvarado Hospital / Scripps Chula Vista / Sharp Chula Vista /
UCSD/Thornton
Fallbrook Hospital / Scripps Encinitas / Sharp Coronado / LTACH
Palomar Medical Center / Scripps Green / Sharp Grossmont / Promise Hospital of SD
Paradise Valley Hospital / Scripps Hillcrest / Sharp Mary Birch/Memorial / Vibra Hospital of SD
Pomerado Hospital / Scripps La Jolla / Sharp - All / Other
Rady Children's San Diego / Scripps - All / Tri-City Medical Center
RIVERSIDE COUNTY HOSPITAL PRIVILEGES: Not Applicable YES
SKILLED NURSING CENTER PRIVILEGES / SURGERY CENTER PRIVILEGES

Rev. 7/10/17 Page 1 of 2

PRACTITIONER CONTRACT APPLICATION

SCOPE OF SERVICES:
COMMENTS/BACKGROUND:

C. PRACTITIONER CREDENTIALING STATUS (FOR PHYSICIANS ONLY)

Credentialing Status: CHG ACTIVE NOT ACTIVE WITH CHG
(If not active, complete the following questions) / LICENSE #: CAQH #:
DATE OF BIRTH:
MEDICAL/GRADUATE DEGREE FROM: / DATE RECEIVED:
BOARD CERTIFICATION:
BOARD: / ISSUED: / EXPIRES: / SPECIALTY:

D. ELECTRONIC DATA INTERCHANGE (EDI)

DOES ORGANIZATION USE A PRACTICE MANAGEMENT SYSTEM?
YES IF YES, WHICH ONE?
NO / BILLING SERVICE CONTACT INFORMATION:
CONTACT NAME:
E-MAIL:
PHONE #:
FAX #:
EDI READY (ANSI 837 FORMAT)? YES NO
ARE YOU INTERESTED IN SUBMITTING CLAIMS DIRECTLY TO CHG? YES NO (If no, complete following question)
CLEARINGHOUSE NAME (If any):
ADDITIONAL COMMENTS:
FOR CHG USE ONLY
W-9 STATUS: RECEIVED/ON FILE
PENDING / DIAMOND ID #: / VISTAR KEY #:
COMMENTS/NETWORK COMPOSITION:
REVIEW PROCESS
(1)  SCANNED IN VISTAR YES NO / (2) DIRECTOR APPROVED: YES NO / (3) PRE-CRED: YES NO
(4)  CMO APPROVED: YES NO / (5) SST REVIEWED: YES NO / (6) OPS APPROVED: YES NO
(7)  PP: YES NO / (8)  QNXT LOADED: YES NO / (9)  VISTAR FINAL SCAN: YES NO

Rev. 7/10/17 Page 1 of 2