Heritage Summit HealthCare LLC Credentialing  Review—Facility/Hospital  page  1

HERITAGE SUMMIT HEALTHCARE LLC

Credentialing Review—Facility/Hospital Location/billing information Please copy this application to list additional office locations.

1. Facility name

Physical address

City State ZIP

County/Parish Phone ( ) Fax ( )

E-mail address Website (if applicable)

2. Is electronic billing available? .....................................................................................................................Yes or No

If yes, please list the electronic billing company or capability type (PDFs, scans, etc.)

What practice management system do you use?

3. Billing address _______________________________________________________________________ City State ZIP

County/Parish Phone ( ) Fax ( ) 4. Is this location a walk-in clinic? .................................................................................................................. Yes or No

If yes, please provide the hours of operation, including lunch times.

Monday _______ to _______ Thursday _______ to _______ Sunday _______ to _______

Tuesday _______ to_______ Friday _______ to _______ Please indicate lunch time:

Wednesday _______ to_______ Saturday _______ to _______ From _______ to _______

Administrative personnel

5. Administrator/CEO/CFO

Business office manager

Utilization review supervisor

Contract negotiator

Heritage Summit HealthCare LLC Credentialing  Review—Facility/Hospital  page  2

Facility

6. Is this facility corporate owned?.................................................................................................................. Yes or No

If yes, by whom?

7. If applicable, please complete the corporate ownership information below.

Name

Address

City State ZIP

County/Parish Phone ( ) Fax ( )

Contact person

E-mail address Website (if applicable)

8. Professional license number NPI

Medicare number Medicaid number

ASC license number FEIN

9. Name of professional liability carrier

Policy number

Amount of coverage Staff

10. Number of active physicians on staff Number of physicians on staff

Number of board-certified physicians Number of nurses on staff

11. Number of nurses on staff LPN ARNP RN CRNA

12. Are the credentials of all your staff verified prior to their employment or affiliation with your facility? .......... Yes or No Please attach a list of all staff physicians, their specialties and credentials.

Heritage Summit HealthCare LLC Credentialing  Review—Facility/Hospital  page  3

Accreditations

13. JCAHO accredited .................................................. Yes or No Date of last accreditation

Medicare approved.................................................. Yes or No Date of last inspection

CARF accredited (rehab hospital only) .................. Yes or No Date of last accreditation

Please enclose copies of your most recent accreditations.

14. Please attach current copies of the following:

Professional business license

Professional liability insurance coverage

W-9 (taxpayer identification number)

Alabama only—List of all ownership, financial or fiduciary interest facilities

During the contracting process, Heritage Summit HealthCare LLC reserves the right to utilize your facility/hospital services for workers’ compensation care.

___________________________________ ________________________ Applicant signature Date

( ) Print name and title of person completing this application Direct phone number

(For office use only)

Heritage Summit HealthCare LLC signature Date Facilities Only

Type of facility: Ambulatory surgery center Home health

Other (please define)

Note: All physicians will need to apply to and be accepted by Heritage Summit HealthCare LLC in order to provide network services.

Heritage Summit HealthCare LLC Credentialing  Review—Facility/Hospital  page  4

Hospitals Only

Type of hospital

Bed counts

Intensive care unit

Critical care unit

Progressive care unit

Medical

Surgical

Other (please define)

Orthopedic

Obstetrics/Gynecology

Skilled nursing

Pediatric

Please check which services are available in your hospital:

Physical therapy

Occupational therapy

Speech programs

CT scan

MRI

Home health

Does your hospital provide occupational medicine? Yes or No If yes, please list name(s) and address(es) below.

Name

Address

Does your hospital provide ambulatory surgery? Yes or No If yes, please list name(s) and address(es) below.

Name

Address

A photocopy of this document shall be as effective as the original. Please return form and attachments to our corporate office (address below).

ELEC SCM003 REV 03/14 (09-477)

HERITAGE SUMMIT HEALTHCARE LLC

CORPORATE OFFICE Florida PO Box 3623 • Lakeland, FL 33802-3623 • 863-665-6629 • 1-800-282-7644 • Fax 863-665-5177

SOUTHEAST REGION Georgia, Kentucky, North Carolina, South Carolina, Tennessee PO Box 600 • Gainesville, GA 30503-0600 • 678-450-5825 • 1-800-971-2667 • Fax 770-531-1349

SOUTHWEST REGION Alabama, Arkansas, Louisiana, Mississippi, Texas PO Box 80793 • Baton Rouge, LA 70898-0793 • 225-928-0820 • 1-888-468-2539 • Fax 225-926-1226

www.summitholdings.com