Provider Participation Request Form Thank you for your interest in joining the Gundersen Health Plan Provider Network. To ensure compliance with our participation policy, we require evidence that you are Medicare and Medicaid eligible, as well as evidence of licensure to operate according to State and Federal regulations. FACILITY NAME:

ADDRESS:

SPECIALTY:

CONTACT NAME:

PHONE:

COVERED SERVICE AREA (city and counties): FACILITY NPI (type 2): MEDICAID NUMBER: MEDICARE NUMBER: TAX ID: INFORMATION BRIEF DESCRIPTION ABOUT YOUR FACILITY, SERVICES, AND YOUR INTEREST IN BECOMING A GUNDERSEN HEALTH PLAN PROVIDER.

PRACTIONER FULL LEGAL NAME

CREDENTIALS NPI (type 1)

PRACTICE LOCATIONS

WI MEDICAID NUMBER

MEDICARE NUMBER

Please also attach the following items and complete the attached information specific to your services. • W9 form • Fee schedule PLEASE RETURN TO: [email protected], FAX: (608) 775-8719, or US Mail at Gundersen Health Plan, Provider Network Administrator, 1900 South Avenue, Mail Stop: NCA 2-01, La Crosse, WI 54601

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GUNDERSEN HEALTH PLAN FACILITY OPERATIONS FORM FOR NEW APPLICANTS SECTION I: FACILITY INFORMATION Please verify all information and complete all blank areas. Enter N/A if not applicable. Facility Name: Address: City, State, Zip Code: Mailing Address: Mailing City, State, Zip: Billing Address: Billing City, State, Zip: Phone Number: 2nd Phone Number: Fax Number: Swing Bed (Y or N): Office Hours:

Tax ID Number: Facility NPI Number: Rural Health Clinic (Y or N):

Does your facility have a restraint policy regarding patient restraints?

Yes

No

Is public transportation accessible to and from your facility?

Yes

No

SECTION II: FACILITY CONTACT INFORMATION Please verify all information and complete all blank areas. Contact Type

Administrator:

Contact Name (First and Last Name)

Title/Position

E-mail Address (if available)

Do you prefer to be contacted via e-mail? Yes ˆ No ˆ

Contract Signature:

Yes ˆ No ˆ

Office Manager:

Yes ˆ No ˆ

Billing: Agreement Notification: Credentialing: Provider Manual:

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Yes ˆ No ˆ Yes ˆ No ˆ Yes ˆ No ˆ

Yes ˆ No ˆ

SECTION III: CERTIFICATION/LICENSE INFORMATION – INITIAL A. Using the table below, please update and/or verify any information that may already have been provided and complete all other pertinent columns to the right of each section. Certification/License Type

Indicate Yes or No

Number

Expiration Date

Most Recent Survey Passed?

Yes ˆ No ˆ

Yes ˆ No ˆ

Medicaid Certified:

Yes ˆ No ˆ N/A ˆ Yes ˆ No ˆ N/A ˆ

Joint Commission (TJC):

Yes ˆ No ˆ Yes ˆ No ˆ N/A ˆ Yes ˆ No ˆ N/A ˆ

Yes ˆ No ˆ N/A ˆ Yes ˆ No ˆ N/A ˆ Yes ˆ No ˆ N/A ˆ Yes ˆ No ˆ N/A ˆ Yes ˆ No ˆ N/A ˆ

Yes ˆ No ˆ N/A ˆ

Yes ˆ No ˆ N/A ˆ

Facility State License: Medicare Certified:

Critical Access Hospital: CLIA or CLIA Waiver: (circle appropriate one)

DMEPOS Accreditation: Other Accrediting Body/Bodies: (circle appropriate one or add any additional certifications)

Current Malpractice Insurance or Facility Liability Insurance: (List the dollar amount in a field to the right)

Monitoring of Employee Sanctions: (Provide copy of policy)

Date Survey Passed

AAAHC, CARF, CCAC, CHAPS Yes ˆ No ˆ

Done annually? Yes ˆ No ˆ

B. Documentation: The documents below that are marked with an “x” are in our possession. For any boxes that are not marked, you must attach copies of those documents to this application. State License(s) Evidence of Medicare Certification (ex: letter of approval or signed participation agreement) Evidence of Medicaid Certification, if applicable (ex: letter of provider approval) CLIA Certificate or Certificate of Waiver Evidence of current Accreditation (such as a certificate or letter of approval) with one of the Accrediting Body/Bodies noted above. If you are not accredited, please proceed to Section C. Include explanations regarding current loss or change of certification or accreditation status THIS BOX FOR HOSPITALS ONLY: Provide a copy of your Medical Staff Service Plan, By-laws, or equivalent, attesting to the process for verifying the credentials of the medical staff providing services in your facility. C. For facilities without accreditation (e.g., if you do not have TJC, AAHC, CARF, CCAC or CHAPS accreditation), please attach the most recent full report of one of the following surveys, including plan of correction if applicable, as well as the letter, or other proof of recertification: CMS (Medicare) Survey, or State Survey, or Critical Access Survey D. For facilities without accreditation (e.g., if you do not have TJC, AAHC, CARF, CCAC or CHAPS accreditation), and are without any of the above named surveys, please note: Gundersen Health Plan Contracts and Provider Relations reserves the right to conduct an on-site visit of your facility.

SECTION IV - ATTESTATION I verify that all of the information provided is current, correct and complete as of the date of my signature below and that at a minimum, the staff are legally and professionally qualified for the positions they hold and that there are no state or federal sanctions against this facility. As an administrative representative of this facility, I have the authority to sign on behalf of the organization. Signature: _____________________________________ Title: ______________________________ Date: ____________________ Page 3 of 9

SECTION V - PRACTITIONERS Please list the names and specialties below of the practitioners employed at your facility. Attach an additional listing, if necessary. Practitioner Name

Specialty

Gender

o Female o Male

o Female o Male

o Female o Male

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Accepting New Patients

o Yes o No

o Yes o No

o Yes o No

Race

o o o o o o

Caucasian African American Hispanic/Latino Asian American Indian Native Hawaiian or Other Pacific Islander o Other __________

o o o o o o

Caucasian African American Hispanic/Latino Asian American Indian Native Hawaiian or Other Pacific Islander o Other __________

o o o o o o

Caucasian African American Hispanic/Latino Asian American Indian Native Hawaiian or Other Pacific Islander o Other __________

Culture

NPI#

Enrolled in Medicare

Medicaid Certified

Medicare #

Medicaid #

______________

_________

o Yes o No o Participating o NonParticipating

o Yes o No

o Accepting Assignment o Not Accepting Assignment Medicare #

Medicaid #

______________

_________

o Yes o No o Participating o NonParticipating

o Yes o No

o Accepting Assignment o Not Accepting Assignment Medicare #

Medicaid #

______________

_________

o Yes o No o Participating o NonParticipating o Accepting Assignment o Not Accepting Assignment

o Yes o No

Practitioner’s Organizational Email

SECTION VI: SERVICES Please review each service listed and indicate the services provided by your facility:

AMBULANCE SERVICES Ambulance Services Other: BEHAVIORAL HEALTH SERVICES Mental Illness Adult– Inpatient Treatment Mental Illness Child/Adolescent–Inpatient Treatment Mental Illness Adult – Outpatient Treatment Mental Illness Child/Adolescent – Outpatient Treatment AODA Adult – Inpatient Treatment AODA Adolescent – Inpatient Treatment AODA Adult – Outpatient Treatment AODA Adolescent – Outpatient Treatment Other: EYE CLINICS SERVICES Eye Glasses & Contacts Ophthalmology Services Optometry Services Vision Care/Screening Vision Supplies (Eye Glasses & Contacts) Other: DURABLE MEDICAL EQUIPMENT SERVICES Apnea Monitors BI-Pap CPAP DME/HME (standard wheelchair, hospital bed, etc.) Oxygen Concentrator Oxygen-Liquid Photo Therapy Ventilators Other: HOME HEALTH SERVICES Durable Medical Equipment Home Infusion Home Health Services (other) Occupational Therapy (Outpatient) Physical Therapy (Outpatient) Speech Therapy Other:

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NURSING HOME SERVICES Skilled Nursing Services Other: PATHOLOGY SERVICES Pathology Services (Professional) Pathology Services (Technical) Other: PODIATRIC SERVICES Laboratory Services (In-house) Radiology – Diagnostic & Therapeutic Podiatric Services Other:

PROSTHETICS/ORTHOTICS SERVICES Mastectomy Supplies Orthotic Supplies Prosthetic Supplies Other: RADIOLOGY SERVICES

Bone Density Measurement CT (Professional) Diagnostic & Therapeutic Radiology MRI (Professional) MRI (Technical) Nuclear Medicine Nuclear Medicine (Professional) Radiation Oncology Radiation Therapy Radiology – General Services (Technical) Radiology Services – Diagnostic & Therapeutic Radiology Services – Mammography Ultrasound Other: SPORTS MEDICINE SERVICES Durable Medical Equipment (Dispensed In-house) Occupational Therapy (Outpatient) Physical Therapy (Outpatient) Orthotic Supplies Prosthetic Supplies Radiology – Diagnostic & Therapeutic (In-house) Orthopedic Surgery (Adult) Orthopedic Surgery (Pediatric) Other:

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OTHER SERVICES Anti-Hemophiliac Factor Anesthetists Bone Growth Stimulator Cardiac Telemetry ECG Interpretation Insulin Pump Therapy Mobile Cardiac Outpatient Telemetry Open MRI Respiratory DME Specialty Clinic TENS Unit Wound Vac Urgent Care Services Other:

CLINIC SERVICES Allergy Services Audiology – Hearing Screening Audiology – Hearing Aids Behavioral Health: Mental Illness Adult – Outpatient Treatment Mental Illness Child/Adolescent – Outpatient Treatment Alcoholism/Chemical Dependency Adult – Outpatient Treatment Alcoholism/Chemical Dependency Adolescent – Outpatient Treatment Cardiology Services Dental Services Dermatology Services Durable Medical Equipment Endocrinology Services Eye Glasses & Contacts Family Practice Gastroenterology Services Hematology/Oncology Services Infectious Disease Services Internal Medicine Services Laboratory Services Nephrology Services Neurology Services Neurosurgery Obstetrics & Gynecology Occupational Health Services Occupational Therapy (Outpatient) Ophthalmology Services Optometry Services Oral/Maxillofacial Surgery Orthopedics Services Otolaryngology (ENT) Pediatric Services Page 7 of 9

CLINIC SERVICES Physical Medicine & Rehabilitation Physical Therapy (Outpatient) Plastic & Reconstructive Surgery - General Podiatric Services Orthotic Supplies Prosthetic Supplies Pulmonary Medicine Services Radiation Therapy Radiology Services – Diagnostic & Therapeutic Radiology Services – Mammography Renal Dialysis Rheumatology Services Speech Therapy Sports Medicine Services Surgery - Outpatient or Ambulatory Urgent Care Services Urology Services Other: HOSPITAL SERVICES Acute Inpatient Hospital Care Audiology – Hearing Screening Audiology – Hearing Aids Behavioral Health: Mental Illness Adult– Inpatient Treatment Mental Illness Child/Adolescent–Inpatient Treatment Mental Illness Adult – Outpatient Treatment Mental Illness Child/Adolescent – Outpatient Treatment Alcoholism/Chemical Dependency Adult – Inpatient Treatment Alcoholism/Chemical Dependency Adolescent – Inpatient Treatment Alcoholism/Chemical Dependency Adult – Outpatient Treatment Alcoholism/Chemical Dependency Adolescent – Outpatient Treatment Cardiology Services Cardiovascular Surgery Dental Services Durable Medical Equipment Emergency & Trauma Center Endocrinology Services Gastroenterology Services Hematology/Oncology Services Infectious Disease Services Laboratory Services Neonatal Intensive Care Unit Neurology Services Neurosurgery Occupational Health Services Occupational Therapy (Inpatient) Occupational Therapy (Outpatient) Page 8 of 9

HOSPITAL SERVICES Ophthalmology Services Oral/Maxillofacial Surgery Orthopedic Surgery (Adult) Orthopedic Surgery (Pediatric) Otolaryngology (ENT) Pediatric Services Physical Medicine & Rehabilitation Physical Therapy (Inpatient) Physical Therapy (Outpatient) Plastic & Reconstructive Surgery - General Orthotic Supplies Prosthetic Supplies Pulmonary Medicine Services Radiation Oncology Services Radiology Services – Diagnostic & Therapeutic Radiology Services - Mammography Renal Dialysis (Outpatient) Rheumatology Services Speech Therapy (Outpatient) Surgery – Outpatient or Ambulatory Surgery (General) Swing Bed – (Skilled Nursing Services) Urgent Care Services Urology Vascular Surgery Other:

SECTION VII - LANGUAGES Please indicate below all languages spoken by employees of your facility.

SECTION VIII - ATTESTATION I verify that all of the information provided is current, correct and complete as of the date of my signature below and that at a minimum, the staff are legally and professionally qualified for the positions they hold and that there are no state or federal sanctions against this facility. As an administrative representative of this facility, I have the authority to sign on behalf of the organization.

Signature

Title

™ Thank you! We appreciate your time and effort! ™

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Date