Page 10S-2324 3/12
Wellmark, Inc.Universal Facility & Entity Application Addendum
To apply for participation in Wellmark networks, please complete this Addendum in combination with the Iowa Statewide Universal Facility Application. Mark N/A for the questions that are not applicable to your facility type. For specific contracting and credentialing requirements, review the Contracts and Credentialing section of the Wellmark Provider Guide, on the Provider section of Wellmark.com.
ADDITIONAL DOCUMENTATION TO INCLUDE:
• CMSApprovalLetter:hospital,hospice,skillednursingfacility,dialysiscenter,homehealthagency,ambulatorysurgerycenter,freestandingsubstanceabusefacility,ruralhealthclinic,federallyqualifiedhealthcenter,homeinfusiontherapy
• CMSSurveydocumentandcoverletterifnotnationallyaccredited:ambulatorysurgerycenter,freestandingsubstanceabusefacility/chemicaldependencytreatmentfacility,homehealthagency,hospice,hospital/specialtyhospital,skillednursingfacility
SECTION M. GENERAL INFORMATION
SchedulingPhoneNumber ________________________ TDDPhoneNumber(hearingimpaired) __________________
Administrator’sName ___________________________ Administrator’s email address _________________________
CredentialingContactName _______________________ Credentialingemailaddress ___________________________
CredentialingAddress _______________________________________________________________________________
CredentialingCity,State,Zip __________________________________________________________________________
CredentialingPhonenumber __________________________________________________________________________
Whatlanguagesarespokenatthisaddress? ______________________________________________________________DoyoubillelectronicallytoWellmarkforfacilityservices? Yes NoDoyoubillelectronicallytoWellmarkforprofessionalservices? Yes NoDoyoustoreelectronicmedicalrecords? Yes NoDoesyourlocationhavepublictransportationaccess? Yes NoDoyouhavetheabilitytosubmitclaimstoCMS? Yes No
Doesyourorganizationownorhaveownershipinterestinahealthcarefacilityororganizationwithwhichyouareaffiliated?(independentlab,nursinghome,retailpharmacy,freestandingradiology/imagingcenter,rehab,freestandingsleepcenter,durablemedicalequipmentsupplier)? Yes No
Ifyes,pleaseprovidenameoffacility,address,percentofownership,ownedby,nameoforganization. ___________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Inwhatnetworksdoesyourfacilityorentitywishtoparticipate?ClassicBlueAllianceSelectSelectFirstTRICAREBlueAccessBlueChoiceBlueAdvantageMedicareAdvantage
SECTION N. EFFECTIVE DATE
WhatistheeffectivedatetoperformservicesforWellmarkmembers? ___________________________________________
Radiology Center Services/CapacityPlease check the services that are available at your hospital/facility. These may or may not be a covered benefit.
BoneScan NuclearMedicine
CTScan PETScan
DEXAScan PET/CT
Echocardiography PET/CTA
Mammography RadiationTherapy
MRA UltraSound
MRI
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SECTION R. DURABLE MEDICAL EQUIPMENT SUPPLIER
•PleaseprovideaccreditationinformationinSectionEofthisapplication.•Ifyouprovideorthoticsandprosthetics,seeSectionWbelow.
IfyoudonothavetheabilitytobillCMS,pleaseexplain: _____________________________________________________
SECTION P. PROFESSIONAL LIABILITY INSURANCE
WellmarkneedsliabilityinformationtocoveryoureffectivedateandalsowhenyouarecredentialedbyWellmark.IftheliabilityinformationinSectionEofthisapplicationdoesn’tcoverbothofthosedates,pleaseprovideadditionalcoverageinformation.
CarrierName ____________________________________ City/State ____________________________________
PolicyNumber ___________________________________
$ Amounts Per Occurrence __________________________ $ Amounts Aggregate ____________________________
Datefrom(mm/dd/yyyy)______/______/______ Dateto(mm/dd/yyyy)______/______/______
SECTION Q. AMBULANCE SERVICE
Doesyourambulanceserviceoperateondonations? Yes No
Doesyourambulanceservicechargeaflatfeeforservices? Yes No
Isyourambulanceservicehospitalbased? Yes No
Ifyes,pleaseprovidethenameofthehospitalandlocation.
Nameofhospital: __________________________________________________________________________________
City,State: _______________________________________________________________________________________
SECTION O. PROVIDER IDENTIFICATION NUMBERS
Doyoucurrentlyhaveastatecertificationnumber? Yes NoIfyes,pleaselist: ____________________________EnteryourNationalProviderIdentifier(NPI)number.
Acutehospital ____________________Ambulance ______________________AmbulatorySurgeryCenter __________CMHC _________________________Dialysis ________________________DME ___________________________FQHC __________________________Freestanding Radiology ____________
HomeHealthAgency ______________HomeInfusionTherapy ____________Hospice ________________________IndependentLab __________________Orthotic/Prosthetic ________________PMIC __________________________Psychiatric ______________________PublicHealthAgency ______________
Rehab __________________________RuralHealthClinic ________________SkilledNursing ___________________SleepCenter _____________________Swing-bed ______________________VisitingNurseAssociation ___________Other: _________________________
Ifyouhavemultiplefacilities,pleaselisteachnameinSectionEE.
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SECTION R. DURABLE MEDICAL EQUIPMENT SUPPLIER (cont.)
Check supplies provided
AirMattress(tech) AugmentativeDevice(tech) Back-UpEquipment(tech)
BathChair(medsupp) Bi-Pap(resp)(tech) BreastPumps(medsubb)
ChestCompressionApparatusfor CysticFibrosis(resp)
CPMMachine(tech) Commodes(medsupp)
ComputerSoftware(tech) DiabeticShoes/Inserts(tech) DiabeticSupplies(medsupp)
EasyStander(tech) EmergencyMaintenance(tech) Enteral(medsupp)
EZLockWheelchair(mobile) FeedingPumps(tech) GrabBars(tech)
HandControlforVehicle(mobile) HearingAids(other) HomeCare(other)
HospitalBeds(tech) InfusionPumps(tech) InfusionTherapy-Adult(medsupp)
InfusionTherapyPediatric(medsupp) JazzyWheelchair(mobile) MechanicalVentilators(resp)
MedicalEquipmentRepairs/Service(tech) MedicalSupplies(medsupp) Ostomysupplies(medsupp)
Parenteral(medsupp) PediatricVents(resp) PulseOximeter(tech)
Respiratory(resp) RespiteCare(other) RestrainSystem(medsupp)
RT-300ErgometerCycle(tech) SpecializedBeds(tech) TPN(medsupp)
Urinary supplies VanLift(mobile) Walker(medsupp)
SpecialWheelchair-custom(mobile) SpecialWheelchair-Manual(mobile)
WheelchairLiftCar(mobile)
WoundCaresupplies
SECTION S. FREESTANDING SUBSTANCE ABUSE CENTERS/CHEMICAL DEPENDENCY TREATMENT FACILITIES
•PleaseprovideacopyofthecompleteStateInspectionReport
•PleaseprovideaccreditationinformationinSectionEoftheapplication
•TRICARErequirescertificationbyKePro(www.kepro.com)
Isyourfacilityequippedtoprovideacuteinpatientmanagement24hoursaday? Yes No
Howmanybedsdoyouhaveavailableforacutetreatment? ___________________________________________________
SECTION T. HOSPITAL/SPECIALIZED HOSPITAL
•Pleaseprovideaccreditation/certificationinformationinSectionEoftheapplication.•TRICARErequiresfreestandingmentalhealthinstitutionsandpartialhospitalizationprogramstobecertifiedbyKePro(www.
kepro.com)
TraumaLevel:Level1Level2Level3Level4Level5Notapplicable
DoyouparticipatewiththeNationalDisasterMedicalServices(NDMS)? Yes No
Check services provided
AcuteCare Alcohol/ChemicalDependency- AdolescentDetox
Alcohol/ChemicalDependency- Adolescent OP
Alcohol/ChemicalDependency- AdolescentPartialHospitalization
Alcohol/ChemicalDependency- AdolescentRehabilitation
Alcohol/ChemicalDependency-AdultDetox
Alcohol/ChemicalDependency-AdultOP
Alcohol/ChemicalDependency-AdultPartialHospitalization
Alcohol/ChemicalDependency-AdultRehabilitation
Ambulance-Air Ambulance-Hospital-based Audiology
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Check services provided
BehavioralHealth BirthingRooms BloodBank
BurnUnit Cancer Cardiac
CardiacRehabilitation CochlearImplantSurgery CTScan
DiabetesEducation Dialysis-OP EEG monitoring
Emergency Room GammaKnife GeriatricServices
HomeHealthServices(notseparatelyMedicarecertified)
HomeInfusionTherapy(not separatelyMedicareCertified
HospiceCare
HyperbaricTreatment ICU-IntensiveCareUnit IOP-IntensiveOtptProgram
Lab-OP LabServices Lithotrispy
Mammography Maternity MRA
MRI NeonatalICULevel1 NeonatalICULevel2
NeonatalICULevel3 NeurologyServices NuclearMedicine
Nursery Obstetrics OccupationalTherapy-IP
OccupationalTherapy-OP OccupationalTherapy-IP/OP Oncology
OpenHeartSurgery OrthopedicServices OutpatientSurgery
PainManagement PartialHospitalization PediatricHematology/Oncology
PediatricICU PediatricEmergencyCare PediatricPhysicalTherapy
PediatricRehabilitation Pediatrics PETScan
PhysicalTherapy-IP PhysicalTherapy-OP PhysicalTherapy-IP/OP
PsychiatricServices-AdolescentEating Disorder PsychiatricServices-AdolescentIP PsychiatricServicesAdolescent
Outpatient
PsychiatricServices-AdolescentPartialHospitalization
PsychiatricServices-AdultEatingDisorder PsychiatricServices-AdultIP
PsychiatricServices-AdultOP PsychiatricServices-AdultPartialHospitalization PsychiatricServicesChildIP
PsychUnit(notseparatelyMedicarecertified) RadiationCenter Radiation Oncology
RehabUnit(notseparatelyMedicare certified) ResidentialCare SleepStudies
SNFUnit(notseparatelyMedicarecertified) SpeechTherapy-IP SpeechTherapy-OP
SpeechTherapyIP/OP SportsMedicine SwingBed(notseparatelyMedicarecertified)
Transplant-BoneMarrow Transplant-Cornea Transplant-Heart
Transplant-Heart/Lung Transplant-Kidney Transplant-Liver
Transplant-Liver/Kidney Transplant-Pancreas/Kidney Transplant-SmallIntestine
Transplant-SmallIntestine/Liver Transplant-Tissue TraumaticBrainInjury
UltraSound UrgentCare VentilatorCare
SECTION T. HOSPITAL/SPECIALIZED HOSPITAL (cont.)
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SECTION V. ORTHOTICS/PROSTHETICS
SECTION W. PUBLIC HEALTH AGENCY/VISITING NURSE ASSOCIATION
• PublicHealthAgency:PleaseprovidedocumentationfromtheBoardofSupervisorsorBoardofHealthdesignatingyouragencyasthepublichealthagencyforyourcounty/area
• VisitingNurseAssociation:PleaseprovidedocumentationfromCMSindicatingyourabilitytobillforimmunizationsgiventoMedicarebeneficiaries
AsaPublicHealthAgency,whichcountieshaveyoubeendesignatedasthepublichealthagency? _____________________
________________________________________________________________________________________________
AsaVisitingNurseAssociation,areyouamemberoftheVisitingNurseAssociationofAmerica? Yes No
AsaVisitingNurseAssociation,areyoucertifiedbyCMStobillimmunization? Yes No
• PleaseprovideAccreditationinformationinSectionEofthisapplication.Ifyouonlyprovidemastectomyfitting,youmusthaveanABCorBOCcertifiedfitteronstaff.Pleaseprovidethefitter’snameandcertificationinformationincludingcertificationdates.
______________________________________________________________________/______/______Name Certification CertificationDate(mm/dd/yyyy)
Whatservicesdoyouprovide(markallthatapply)?Orthotics Prosthetics Mastectomy Ocularist
SECTION U. INDEPENDENT LABORATORY
WhatlevelofCLIAcertificationdoesthelabhave? Accreditation Waiver Compliance Registration
Provider-PerformedMicroscopyProcedures
NameofthefacilityontheCLIAcertificate _______________________________________________________________
SECTION X. PSYCHIATRIC MEDICAL INSTITUTIONS for CHILDREN
•PleaseprovideaccreditationinformationinSectionEofthisapplicationHowmanybedsdoyouhaveavailablefortreatment?_____________________
Howmanyhoursperdayofonsitenursingareavailable?Lessthan8hours8ormorehours
IsaRNavailable24hoursaday,7daysaweek? Yes No
Doyouhaveoneormorefulltimestaffpsychiatrists? Yes No
Ifyes,pleaseprovidethenameandstatelicenseinformationbelow.
______________________________________ ___________________ __________ ______/______/______Name LicenseNumber State EffectiveDate(mm/dd/yyyy)
______________________________________ ___________________ __________ ______/______/______Name LicenseNumber State EffectiveDate(mm/dd/yyyy)
______________________________________ ___________________ __________ ______/______/______Name LicenseNumber State EffectiveDate(mm/dd/yyyy)
Check services/supplies provided
Back-UpEquipment CustomFabricatedOrthotics CustomFitOrthotics
DiabeticShoes/Inserts EmergencyMaintenance LimbProsthetics
MedicalEquipmentRepairs/Service OfftheShelfOrthotics OrbitalProsthesis
Orthotics Prosthetics ProstheticDevices
Respiratory
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Imaging Equipment Used at this SitePleaselisteachpieceofequipmentusedtoprovideservices.IndicateTypeofServiceinthe“Type”column-CT,CTA,NuclearCardiology,PET,PET/CT,MRI,MRA,Echocardiography,Other(specify).Completeallinformationrelatedtothatpieceofequipment.
Type Manufacturer Model Year
SECTION Y. RADIOLOGY/IMAGING CENTER
TypeofServices CheckifServiceisOffered
AccreditedBy (OrganizationName(s))
Date Accredited Accreditation Renewal Date
CT // //
CTA // //
NuclearCardiology // //
PET // //
PET/CT // //
Mammography // //
MRI // //
MRA // //
Echocardiography // //
Other(specify) // //
Other(specify) // //
Other(specify) // //
Other(specify) // //
•PleaseprovideaccreditationinformationinSectionEofthisapplication
SECTION Z. RURAL HEALTH CLINICS / FEDERALLY QUALIFIED HEALTH CENTERS
•RuralHealthClinics:PleaseprovideacopyoftheInterimRateLetter.FacilityType: RHC FQHC–rural FQHC-urban
ListtheIowacountieswhereyouprovideservices. __________________________________________________________
ListtheSouth Dakotacountieswhereyouprovideservices. ___________________________________________________
Providetherequestedinformationregardingallofthephysiciansand/orpractitionersatyourclinicinthetablebelow.
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SECTION AA. SLEEP CENTERS – FREESTANDING OR HOSPITAL-BASED
•Tobelistedintheproviderdirectory,yoursleepcentermustbecontractedandcredentialed.•PleaseprovideaccreditationinformationinSectionEofthisapplication.
Howmanybedsdoyouhaveavailableforsleepstudies? ____________________________________________________DoyouhaveamedicaldirectororstaffphysicianwhoisBoardCertifiedinSleepMedicine? Yes NoIfyes,pleaseprovidethename(s)below.
____________________________________________ _____________________ ______/______/______Name Board ExpirationDate(mm/dd/yyyy)
____________________________________________ _____________________ ______/______/______Name Board ExpirationDate(mm/dd/yyyy)
____________________________________________ _____________________ ______/______/______Name Board ExpirationDate(mm/dd/yyyy)
Isyourmedicaldirectororstaffphysicianavailabletoprovideface-to-facereviewofstudyresultstosleepcenterpatients? Yes No
SECTION BB. SKILLED NURSING FACILITY
•Pleaseprovideaccreditation,certificationandlicensureinformationinSectionEofthisapplication.
Physician/PractitionerName,degree/title(List every physician or practitioner providing care at the RHC or
FQHC)
NPI(if applicable)
Willthisphysicianorpractitionerbillforservicesoutsideofthe
encounterrate?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Mark services provided
BehavioralHealthDualDiagnosis CardiacDrips CardiacRehabilitation
HemoDialysis HyperbaricTreatment Inpatient
IV Administration LevelsofCare NeurologyServices
OccupationalTherapy-IP OccupationalTherapy-IP/OP OccupationalTherapy-OP
OrthopedicServices OstomyCare OxygenTherapy
Pediatrics Pediatric Vents PostHospitalization
Post Transplant PhysicalTherapy-IP PhysicalTherapy-IP/OP
PhysicalTherapy-OP ResidentialCare Specialized/ComplexWoundCare
SpecialtyBeds(types) SpeechTherapy-IP SpeechTherapyIP/OP
SpeechTherapy-OP SuctionTherapy Trachs
Transportation TraumaticBrainInjury Vents
WoundCare Wound Vac
SECTION Z. RURAL HEALTH CLINICS / FEDERALLY QUALIFIED HEALTH CENTERS (cont.)
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SECTION CC. HOME INFUSION THERAPY PROVIDERS
•PleaseprovideaccreditationinformationinSectionEofthisapplication.
Whattypeofpharmacylicensedoyouhold? General HospitalNon-Resident
Yes NoDoesthislocationmeettheStatesterilecompoundingrequirements?
Yes NoIsthislocationrecognizedbyCMSasaDMEsupplierandapharmacy?
Yes NoDoestheMedicalDirectorhaveexpertiseininfusiontherapyservicestoprovideoveralldirectionfortheclinical apsectofthehomeinfustiontherapy?
Yes NoDoesthislocationhaveamedicaldirectororRNthatdevelops,coordinatesandsupervisesallactivitiesofnursing services,includingresponsibilityforassuringthatonlyqualifiedindividualsadministerhomeinfusiondrugs?
Yes NoAreRNsprovidingdirectpatientcare?
Yes NoDoyousubcontactforthenursingservices?
Ifyes,pleaseprovidethenameoftheagencyusedforsubcontractedservices: _________________________
____________________________________________________________________________________
Yes NoDoyoudeliverinfusionserviceswithin24hoursofreceiptofphysician’sorder?
Yes NoDoyouhaveasystemensuringpromptdeliveryandappropriatestorageofpharmaceuticals,suppliesand maintenanceandserviceofequipment?
Yes NoDoyouprovideamedicalwastedisposalsystemforin-homeuse?
Yes NoDoyouhaveadocumentedrecallpolicyandprocedureintheeventofanFDArecallonaninfusionproduct?
Yes NoDoyouprovidecareundergeneralsupervisionofpatient’sphysician?
Yes NoIstheplanofcarereviewedatleastevery30daysorasoftenasthepatient’sphysiciandeemsnecessary?
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SECTION DD. CORPORATE CONTRACTS LIST OF LOCATIONS - To be used by Corporate Providers
Listoflocations–includeanylocationsinIowa,SouthDakotaorcountiesborderingeitherstatePleasecompletetheinformationbelowforeachlocationorifyouhaveaspreadsheetthatwouldincludeallofthisinformation,pleaseattachittothisapplication.Ifadditionalspaceisneeded,pleasecopythispage.Wellmarkwilldetermineeligibilityfornetworksaccordingtoourrequirementsandeachspecificlocation.
CheckiftheAPPLICATIONCONTACT(SectionB)isthesameforallyourlocations.Ifnot,pleaseprovidethisinformationperlocationinSectionFF.
CheckiftheBILLINGINFORMATION(SectionC)isthesameforallyourlocations.Ifnot,pleaseprovidethisinformationperlocationinSectionFF.
CheckhereiftheMEDICALDIRECTOR(SectionD)isthesameforallyourlocations.Ifnot,pleaseprovidethisinformationperlocationinSectionFF.
CheckhereiftheACCREDITATION/CERTIFICATION/LICENSUREINFORMATION(SectionE)appliestoallyourlocations.Ifnot,pleaseprovidethisinformationperlocationinSectionFF.
CheckhereiftheLIABILITYINFORMATION(SectionsF&Q)appliestoallyourlocations.Ifnot,pleaseprovidethisinformationperlocationinSectionFF.
NPI: _______________________________________ TIN(if different at this site): ______________________________
StateCertificationNumber: _____________________ Whichstate(s)? _______________________________________
Name: ___________________________________________________________________________________________
Street: ___________________________________________________________________________________________
City,State,Zip: _____________________________________________________________________________________
SchedulingPhoneNumber: ______________________ TDDPhonenumber(hearing impaired): _____________________
EffectiveDatetoSeeWellmarkmembers: _________________________________________________________________
Languagesspokenatsite: _____________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________________________________________________
NPI: _______________________________________ TIN(if different at this site): ______________________________
StateCertificationNumber: _____________________ Whichstate(s)? _______________________________________
Name: ___________________________________________________________________________________________
Street: ___________________________________________________________________________________________
City,State,Zip: _____________________________________________________________________________________
SchedulingPhoneNumber: ______________________ TDDPhonenumber(hearing impaired): _____________________
EffectiveDatetoSeeWellmarkmembers: _________________________________________________________________
Languagesspokenatsite: _____________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________________________________________________
NPI: _______________________________________ TIN(if different at this site): ______________________________
StateCertificationNumber: _____________________ Whichstate(s)? _______________________________________
Name: ___________________________________________________________________________________________
Street: ___________________________________________________________________________________________
City,State,Zip: _____________________________________________________________________________________
SchedulingPhoneNumber: ______________________ TDDPhonenumber(hearing impaired): _____________________
EffectiveDatetoSeeWellmarkmembers: _________________________________________________________________
Languagesspokenatsite: _____________________________________________________________________________
_________________________________________________________________________________________________
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NPI: _______________________________________ TIN(if different at this site): ______________________________
StateCertificationNumber: _____________________ Whichstate(s)? _______________________________________
Name: ___________________________________________________________________________________________
Street: ___________________________________________________________________________________________
City,State,Zip: _____________________________________________________________________________________
SchedulingPhoneNumber: ______________________ TDDPhonenumber(hearing impaired): _____________________
EffectiveDatetoSeeWellmarkmembers: _________________________________________________________________
Languagesspokenatsite: _____________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________________________________________________
NPI: _______________________________________ TIN(if different at this site): ______________________________
StateCertificationNumber: _____________________ Whichstate(s)? _______________________________________
Name: ___________________________________________________________________________________________
Street: ___________________________________________________________________________________________
City,State,Zip: _____________________________________________________________________________________
SchedulingPhoneNumber: ______________________ TDDPhonenumber(hearing impaired): _____________________
EffectiveDatetoSeeWellmarkmembers: _________________________________________________________________
Languagesspokenatsite: _____________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________________________________________________
NPI: _______________________________________ TIN(if different at this site): ______________________________
StateCertificationNumber: _____________________ Whichstate(s)? _______________________________________
Name: ___________________________________________________________________________________________
Street: ___________________________________________________________________________________________
City,State,Zip: _____________________________________________________________________________________
SchedulingPhoneNumber: ______________________ TDDPhonenumber(hearing impaired): _____________________
EffectiveDatetoSeeWellmarkmembers: _________________________________________________________________
Languagesspokenatsite: _____________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
NPI: _______________________________________ TIN(if different at this site): ______________________________
StateCertificationNumber: _____________________ Whichstate(s)? _______________________________________
Name: ___________________________________________________________________________________________
Street: ___________________________________________________________________________________________
City,State,Zip: _____________________________________________________________________________________
SchedulingPhoneNumber: ______________________ TDDPhonenumber(hearing impaired): _____________________
EffectiveDatetoSeeWellmarkmembers: _________________________________________________________________
Languagesspokenatsite: _____________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________________________________________________
SECTION DD. CORPORATE CONTRACTS LIST OF LOCATIONS - To be used by Corporate Providers (cont.)
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For all Wellmark networks, you must sign and date this section. Please do not back date it. It will be returned if signature date is older than 60 days.
Confirmation of Provider EnrollmentForanelectronicsummaryoftheprovider’snetworkparticipationstatusresultingfromthisapplication,completethefollowingfields.Ifyouwouldlikeotherstoreceivethisinformation,suchasbillingstaff,includee-mailaddressesonthelinesprovided.
PrimaryContact ____________________________________________________________________________
PrimaryContactPhoneNumber _________________________________________________________________
PrimaryContactE-mailAddress _________________________________________________________________
OtherE-mailAddress(es) ______________________________________________________________________
Note:ifacontractisbeingsignedaspartoftheapplicationprocess,thisoptionisnotavailable.Contract(s)andparticipationstatuswillbesentbymail.
Certification and ReleaseIunderstandthatanyinformationenteredonthisapplicationandanyWellmark,Inc.addendaappropriatetomyspecialtywhichsubsequentlyisfoundtobefalsecouldresultinimmediatedismissalfromanyWellmarkprogram.
IherebycertifythattheinformationcontainedinmycompletedWellmarkapplicationisaccurate,trueandcomplete.IauthorizereleaseofinformationasmayberequiredbyWellmarktoprocessthisapplicationandunderstandandagreeWellmarkmaycommunicatewithmethroughvariousmeans,includingbutnotlimitedtotelephone,mail,and/oremailovertheinternetregardingthisapplication.MysignatureonmycompleteapplicationdoesnotconstituteacontractwithWellmark.BysigningthisapplicationwhichrepresentsalladdendabyWellmark,IauthorizeWellmarktoreleasethisinformationtoWellmarksubsidiariesandaffiliates.
AuthorizedSignature_____________________________________________________________/_______/_______ Date (mm/dd/yyyy)
AuthorizedPerson’sNameandTitle(pleasetypeorprint) ____________________________________________________
Certification and Release of the individual preparing the application. Complete this section if this application has been prepared by someone other than the authorized person indicated above - include name and title
I,___________________________________,herebyattestthattheinformationincludedonthisapplicationisaccurate,true,andcompleteandcanberetrievedfromthefileslocatedat
______________________________________________ __________________________ __________________FacilityName StreetAddress City
_________________________________________________ _______/_______/_______Preparer’sSignatureandTitle Date(mm/dd/yyyy)
SECTION EE. CERTIFICATION AND RELEASE
Applicantshavethefollowingrights:•Youmayrequesttoreviewtheinformationsubmittedinsupportofyourcredentialingapplication.•Youmaycorrectanyerroneousinformationfoundinyourcredentialingfile.•Youwillbenotifiedofanyinformationcollectedduringthecredentialingprocessvariessubstantiallyfromtheinformationyousubmitted.
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SECTION FF. ADDITIONAL INFORMATION:
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