Ancillary Credentialing 1.6 20171030

In order to qualify as a participating ancillary Provider for Independence Blue Cross and its affiliates ("Independence"), a Provider must meet requirements which include, but are not limited to the following:

A current unrestricted license as required by state or federal regulations. A certificate of registration is acceptable for durable medical equipment providers in Pennsylvania.
Accreditation by an Independence recognized accrediting body, if required for provider specialty type.
Eligibility in good standing to participate in Medicare, Medicaid and other governmental health programs. In order to participate in any of Independence’s Medicare Advantage benefits programs, Provider must be certified by or participate with Medicare.
Maintenance of professional and property liability at a level that complies with state or federal regulatory requirements or, if not regulated for provider type, meets community standards.
Maintenance of an active, documented quality management program including, at a minimum, the following items with copies of such documentation made available to Independence upon request.
- Structured documents of Providers quality control and improvement program, including their written plan
- Provision for 24 hours/day, 7 days/week emergency coverage
- Process to assure professional staff credentialing/recredentialing, including verifying the credentials of subcontracted individuals
- Structured patient/family satisfaction survey process
Providers must agree that any and all covered services provided to members of Independence will be provided directly by Provider or a subcontractor as specifically approved by Independence. Provider must disclose the name of all organizations with which it subcontracts for covered services, and must assure that subcontracted providers meet Independence’s standards as listed herein. Provider shall ensure that all approved subcontractors are not excluded from participation in Medicare, Medicaid and/or other federal health care programs. Provider understands that the list of excluded individuals and entities are available on the website of the Office of Inspector General.
Provider must have a valid national provider identifier (NPI) and taxonomy number.

Copy of National Provider Identifier and taxonomy number
Copy of incorporation papers and, as applicable, fictitious name filing
Copy of state license, certification, or registration
Copy of final accreditation letter (if applicable)
Copy of CMS or state survey (if applicable)
Medicare and Medicaid information with documentation from CMS
Copy of face sheets for current liability insurance
Description of process to ensure current licensure for professional staff
Description of procedures to assess patient/client satisfaction and summary of last assessment
A completed Personnel Roster form
Copy of W-9 for tax identification number (IRS requirement)

In accordance with our accreditation and/or regulatory requirements, Independence will complete reassessment every three years to ensure Provider's continued compliance.

Independence reserves the right to limit Provider participation with Independence based on its business or network needs.

Email Completed / Saved Application to:

Ancillary Credentialing 1.6 20171030

Ancillary Provider Credentialing Application

Ambulance

Additional Requirements

Providers shall complete the Personnel Roster form listing all licensed/certified staff to demonstrate that it is adequately staffed to provide services 24 hours per day, 7 days per week.
Provider shall have a minimum of two (2) licensed emergency vehicles to provide services for Independence’s membership in the county/counties for which Provider is licensed and shall furnish proof of licensure for each vehicle.
Providers approved as "911"/emergency transport carriers for a county shall furnish documentation to validate their authorization to provide such services.

*NOTE: Independence requires that participating ambulance Providers maintain a minimum of two (2) vehicles and staffing to provide services 24 hours per day for 7 days per week.

Number of licensed ambulance vehicles*:

Provide a copy of the vehicle registration for each ambulance vehicle.

Are any licensed vehicles garaged or maintained at an address that is different than the main office? Yes No

Services:

Please check all services that you provide. Attach a copy of the licensure or certification required by the regulatory agencies for your state/municipality for each service that specifically requires such licensure or certification.

Advanced Life Support (ALS)

Critical Care Transport (requires presence of Registered Nurse on vehicle)

Basic Life Support (BLS)

"911" Services If your organization is a county-sanctioned transport for 911 services, attach documentation from the county (e.g., letter or certification document) to support approval for this service.

If you are an ALS provider, provide the name and address of your Medical Command Hospital:

Medical Service Information:

Describe your process to assure on-going licensure or certification of professional employees–e.g., who monitors the process, how is information maintained, how frequently is information updated.

Submit a description of procedures in place to assess patient/customer satisfaction. Provide a copy of your customer satisfaction survey form and summary of the last assessment.

Staffing:

Personnel Roster Form
Complete and attach the Personnel Roster Form listing all licensed/certified personnel with their license/certification dates. The following individuals currently serve as members/employees of the above mentioned applicant.

How many of your employees, who provide patient care, are certified as the following: (Part time, Full time, paid or volunteer) Count each individual once.

	EMT Basic		EMT Intermediate/Advanced		Paramedic
	CPR Only		State Certified First Responder		All Other

Name of your Medical Director* (Required if ALS certified):

Physician Name	Physician License Number	License Expiration Date

Are drivers Emergency Vehicle Operator course certified? Yes No

Provider Arrangements:

Does your organization have a provider arrangement in place with any acute care hospitals, rehab
hospitals or skilled nursing facilities that participate with Independence? Yes No

Corporate Affiliation:

Is your organization affiliated with any other corporate entity and/or does it operate under any other name? Yes No

Ambulatory Care Facility

Number of procedure suites:
CMS or state survey: Please submit a copy of your most recent CMS or state survey.
Staffing:
Physician Services:
Medical Director
License		Expiration Date
Contracted for Independence’s HMO & PPO Networks			Yes No
If you do not have an anesthesiologist on staff, provide the name and address of the anesthesia group that provides services for your facility.
Name of Group
Address
City	State Zip
Contracted for Independence’s HMO & PPO Networks			Yes No
Transfer Agreements:
Does your facility have a transfer agreement with an acute care hospital?			Yes No
Please provide name of the hospital:
Does your facility have an agreement with an emergency medical transport/ambulance provider?			Yes No
Please provide the name of the provider:
Laboratory and Radiology Services:
Please provide the name and address of the laboratory group that provides services for your facility.
Name of Group
Address
City	State Zip
Please provide the name and address of the radiology group that provides services for your facility.
Name of Group
Address
City	State Zip
* Laboratory and radiology providers must be participating with Independence.

Ambulatory Surgery Center

Birth Centers

Number of birthing rooms or suites:

Staffing:

Provide the number of the following professional providers on staff at your facility:

Certified Nurse Midwives
Nurse Practitioners
Registered Nurses
Other (specify type)
Name of OB/GYN consultant:

Is the OB/GYN consultant contracted for Independence’s HMO and/or PPO products?

Yes No

Provide names, license numbers and expiration dates of all practitioners who provide services at the birthing center. (Attach additional documentation if necessary)

Name	License #	Expiration Date

Provider Agreements:

Does your facility have a transfer agreement with an acute care hospital:

Yes No

Does your facility have arrangements for the provision of ultrasound testing?

Yes No

Clinical Laboratory

Provider Specific Information — Comprehensive Outpatient Rehab Facility

CMS or State Survey: Please submit a copy of your most recent CMS or state survey. A letter from CMS which states that your facility was reviewed and indicates that it passed inspection may be submitted in lieu of the survey report.

Services:

Check all services provided by your facility:

	Physician Services		Physical Therapy
	Occupational Therapy		Respiratory Therapy
	Speech Therapy		Social Services

Staffing:

Please indicate the number of the following professional providers on staff:

Physical Therapist(s)		Speech Therapist(s)
Occupational Therapist(s)		Respiratory Therapist(s)
Medical Social Worker(s)
Other (Describe)

Durable Medical Equipment

Home Health Agency

Please check one of the following. Home Health Agency is: Freestanding Hospital-Based

Service Types:

Adult

Pediatric

Services:

	Skilled Nursing		Speech Therapy
	Physical Therapy		Nutritional Counseling
	Occupational Therapy		Medical Social Services

Staffing:

(Provide the number of the following providers on staff):

	# Employed (including per diem)	# Contracted
Registered Nurse(s):
Licensed Practical Nurse(s):
Home Health Aide(s):
Speech Therapist(s):
Physical Therapist(s):
Occupational Therapist(s):
Registered Dietician(s):
Medical Social Worker(s):

Hours of operation–Indicate hours and days of the week provide services:

	Opening Time	Closing Time
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

Home Perinatal:

Additional Requirements

Provider will use perinatal nurses with a minimum of three (3) years' obstetrics (OB) experience for all high-risk perinatal members referred by Independence’s care Management for the Baby BluePrints program. Nurses assigned to cases requiring infusion services must all be IV-certified.*
Provider will have arrangements for services by a registered dietician, social worker, and perinatal experienced home health aides, as required by the Baby BluePrints program.

* The most current criteria from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) will be used as the standard of proficiency.

If you are interested in participating as a Provider for Independence’s Home Perinatal Program (Baby Blue Prints), complete the following and attach a copy of your agency's policy describing experience requirements for nurses providing Home Perinatal Services.

Specialty Services (Check all services that you provide):

	Perinatal Nursing Services
	Perinatal Home Health Aides
	Nutritional Evaluation by Registered Dietician
	Medical Social Worker

Staffing (Provide the number of the following providers on staff):

	# Employed (including per diem)	# Contracted
Perinatal RNs:
–IV Certified Perinatal RNs:
Medical Social Worker:
Registered Dieticians:
Perinatal Home Health Aides:

Mother's Option Postnatal Program:

Additional Requirements

Provider will use nurses with a minimum of one (1) year postpartum maternal or neonatal experience for maternal discharge visits–i.e., Well Mom/Well Baby visits for Mother's Option program.*
Providers must be able to provide, directly or through subcontracted arrangements, lamb or fiberoptic home phototherapy units (e.g. Wallaby) services.

* The most current criteria from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) will be used as the standard of proficiency.

Postnatal Services*

	Well Mom/Well Baby Visits
	Phototherapy/Wallaby Units	Number of Units:

* Attach a copy of your agency's policy describing experience requirements for nurses providing postnatal services. Participating providers for Mother's Option program services must supply wallaby units for phototherapy either directly or through a sub contractual arrangement.

Staffing (Provide the number of the following providers on staff):

	# Employed (including per diem)	# Contracted
Registered Nurse(s):

Independent Diagnostic Testing Facility

Infusion Therapy (Suite / Home)

Home Infusion Infusion Suite

Additional Requirements

Infusion Therapy Providers must maintain the appropriate state pharmacy and federal DEA licenses

Staffing:

If you provide nursing services, are you licensed as a home health agency?

Yes No

Provide the number of the following providers on staff:

	# Employed (including per diem)	# Contracted
Registered Nurse(s):
Pharmacist(s):
Pharmacy Technician(s):
Other(describe below):

Hospice

Type of hospice:

Freestanding Hospital-Based
Name of hospital/health system:

Services:

	Routine Home Hospice
	Respite Care
	Continuous/Hourly Care
	Inpatient Hospice

Staffing (Provide the number of the following providers on staff):

	# Employed (including per diem)	# Contracted
Registered Nurse(s):
Licensed Practical Nurse(s):
Home Health Aide(s):
Physical Therapist(s):
Occupational Therapist(s):
Social Worker(s):
Dietician(s):
Spiritual Care:

Medical Director (Physician):

Name	Physician License	Expiration Date

Hospital

Mobile Radiology Provider

Services (Please list all x-ray/radiology services your organization provides)

Accreditation:

Your organization is required to be accredited by at least one of the approved three national accreditation organizations. Please check the accrediting organization(s) through which your organization is accredited:

AMERICAN COLLEGE OF RADIOLOGY (ACR)

INTERSOCIETAL ACCREDITATION COMMISSION (IAC)

THE JOINT COMMISSION (TJC)

Provider Arrangements:

Does your organization have referring physicians / providers that have ownership interest in your organization? Yes No

Does your organization have agreements in place to provide services at any skilled nursing facilities? Yes No

Radiology-Diagnostic Imaging Center

Outpatient Diabetes Education

Staffing:

Number of Certified Diabetic Educators on staff with your program:

Renal Dialysis

Skilled Nursing and Subacute Facilities

Note: Independence requires that participating skilled and subacute facilities will accept admissions seven (7) days a week during normal business hours.

CMS or state survey:Please submit a copy of your most recent CMS or state survey. A letter from CMS which states that your facility has reviewed and indicates that it passed inspection may be submitted in lieu of the survey report.

Date of last CMS or State Survey:

Credentialing requested for:

Subacute Rehab

Subacute Medical

Subacute Ventilator

Pediatric Ventilator

Type of Skilled Facility:

Freestanding Facility Hospital-Based Facility

# Licensed Beds: # Medicare Certified Beds:

Services (Complete all that apply to your facility):

	# Beds
Skilled Care:
Subacute Medical:
Subacute Rehabilitation:
Ventilator –Chronic Care and/or Weaning:

Staffing:

Provide the number of the following providers on staff at your facility:

	# Employed (including per diem)	# Contracted
Registered Nurse(s):
Licensed Practical Nurse(s):
Nurse Assistant/Aide(s):
Physical Therapist(s):
Speech Therapist(s):
Respiratory Therapist(s):
Occupational Therapist(s):

Provide the names of physicians with admitting privileges to your facility and if they are contracted to participate in Independence’s HMO or PPO networks. Attach a separate page if necessary.

Admitting Physician	License #	Exp. Date	Contracted for Independence’s HMO&PPO Networks
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No

Complete the following regards the Medical Director for your facility:

Medical Director	License #	Exp. Date	Contracted for Independence’s HMO&PPO Networks
			Yes No

Transfer Agreements:

Does your facility have a transfer agreement with an acute care hospital that is participating with Independence?

Yes No

Does your facility have an agreement with an emergency medical transport/ambulance provider?

Yes No

Therapy Services:

Check number of days per week that therapy services are available for patients:

Five DaysSix DaysSeven Days

Laboratory and Radiology Services:

Explain the arrangements your facility has for routine laboratory and/or radiology services required by patients. If you have sub contractual arrangements with other providers for these services, provide the names and addresses of these providers (attach additional documentation if necessary):

Additional Requirements

Requirements for all Subacute Providers:

Subacute facilities must either (1) be accredited by the Joint Commission or (2) meet Independence’s criteria for subacute providers. The CMS or state review may be submitted in lieu of accreditation. Additionally, a letter from CMS which shows that the facility was reviewed and indicates that it passed inspection is acceptable in lieu of the survey report.
Facilities must have a registered nurse present 24 hours a day/7 days a week in the subacute unit or, if there is not a separate subacute unit, on the floor where subacute services are provided. The Director of Nursing must be a Registered Nurse.
Facility must have a transfer agreement with an Independence participating acute care hospital.
Facility must hold weekly team conferences of interdisciplinary care-givers to discuss and coordinate the care of subacute patients.
Initial physician visit and documentation of treatment plan must be completed within 24 hours of admission.
1. Follow up physician examinations shall occur at least twice weekly for weanable ventilator patients, and at least weekly for all other subacute patients.
2. Subacute facilities must have a physician on call 24 hours day/seven days a week.

Subacute Rehabilitation Providers:

Facility providing subacute rehabilitation must have therapies available a minimum of 6 days a week.
Facility must provide a minimum of 2 hours of rehabilitative care a day for subacute rehab patients.

Subacute Ventilator Providers:

Facility must evaluate ventilator patients prior to admission to determine if patient is weanable or chronically ventilator dependent. This evaluation must be performed by a qualified pulmonologist.
Facility caring for ventilator patients shall have a staff physician available for 24 hours a day.
Facility caring for ventilator patients must have a registered nurse and respiratory therapist offering continuous care on the subacute unit 24 hours a day.

Residential Pediatric Ventilator Facility:

The facility shall have a defined Residential Pediatric Ventilator Program with the appropriate Department of Public Welfare (DPW) licensure, and the scope of the services and age related admission criteria clearly stated.
Policy and procedure manuals shall be available to staff. These manuals shall be dated, signed and reviewed and revised at least annually. Policies and procedures specific to the facility's Residential Pediatric Ventilator Program shall be maintained.
Job descriptions are specific to Residential Ventilator staff, and define qualifications corresponding to the facility’s program definition. Staff competency is assured, either through requirements for experience, or specific training, followed by documented competency skills check to include Pediatric Respiratory and Ventilator care.
There is a provision to assure that all licensed nurses working in the Residential Pediatric Ventilator facilities program are IV certified, have current CPR certification, and are in compliance with DPW standards/licensure codes.
There is an adequate policy and procedure written for stat and urgent medication and medical emergency treatment situations.
Emergency equipment such as back-up ventilators, generators, and appropriate resuscitation equipment are available at the facility for response to respiratory, cardiopulmonary and other emergencies. Suction equipment, a resuscitation bag, a cardiac board, a sufficient quantity of intravenous fluids, intravenous tubing and percutaneous catheters of various sizes should be available. Supplies should also include devices to maintain an oral airway and to administer oxygen. All supplies should be adequately stored for immediate access in a centralized location.
The Residential Pediatric Ventilator Program shall be overseen by a pulmonologist who is available 24 hours a day, 7 days a week with coverage arrangements. A facility physician will be available 24 hours a day, 7 days a week with coverage arrangements. A Registered Nurse and Respiratory Therapist shall be on-site 24 hours a day, 7 days a week. The staffing ration will consist of one (1) nurse to a maximum of four (4) children with adequate support staff to meet the individual needs of each child.
Ventilator patients are evaluated by a pulmonologist prior to admission. This evaluation is documented on the chart.
For Residential Pediatric Ventilator patients, initial physician visit is completed by the physician within 24 hours of admission. There is a written policy regarding the following:
- Physician examination
  - Chronic ventilator dependent patients: weekly
  - Weanable ventilator patients: twice weekly
- Facilitation of changes in Respiratory (ventilator settings) orders.
Weekly team conferences are held to coordinate the care of pediatric ventilator patients. Documentation of this conference is included in the patient's chart.
The site affords a safe, clean environment for staff, patients and visitors.
Patients are provided privacy in accordance with facility confidentially policy and DPW policy and standards.
IV supplies are readily available.
Medications for emergencies and urgent orders are kept in stock, and all medications are appropriately controlled.
The Provider shall maintain arrangements to assure that other stat medications can be delivered within two hours.
For Providers of Residential Pediatric Ventilator care, therapies that are medically necessary are available at the facility and shall include physical, occupational, and speech therapy. These therapies will be available five days a week.
A durable medical equipment Provider shall be available 24 hours a day, 7 days a week.
The facility must have a transfer agreement with a participating acute care hospital.

Sleep Study Centers

WARRANTY

The information provided in this application and its accompanying documentation may be shared with our subsidiaries and affiliates for assessment and network participation purposes. A subsidiary or affiliate is any corporation or other organization that is or becomes owned or controlled, either directly or through parent corporations, by Independence or under common control with Independence Hospital Indemnity Plan and its affiliates including Keystone Health Plan East (hereinafter referred to collectively as “Independence”). This currently includes the following:

AmeriHealth HMO, Inc
AmeriHealth Insurance Company of New Jersey
AmeriHealth Administrators, Inc. d/b/a AmeriHealth Administrators
HealthCare Delaware, Inc.
Inter-County Health Plan, Inc.
Keystone Health Plan East
Keystone Health Systems
QCC Insurance Company
QCC Insurance Company d/b/a AmeriHealth Insurance Company
QCC Insurance Company d/b/a Independence Administrators

ON BEHALF OF THE PROVIDER, I hereby certify that all the information included in this application and the accompanying documents are correct and complete to the best of my knowledge and belief.

If this application contains either (i) any material omissions, or (ii) false or misleading information, participation with Independence may be terminated.
In the event that there are any changes to any of the information provided in this application, Independence will be notified immediately.

ON BEHALF OF THE PROVIDER, I hereby authorize Independence to verify the information provided on this application and accompanying documentation. I also authorize the release of any relevant information pertaining to organizational status, licensure, accreditation or operations to Independence.

I hereby authorize and agree that Independence, its respective agents, employees, and representatives may provide Independence’s subsidiaries and affiliates with any information concerning the organization's qualifications for the purpose of participation in Independence’s ancillary provider networks. I release Independence, its respective agents, employees, and representatives of any liability for furnishing any such information which is provided in good faith and without malice.

I hereby authorize Independence and its subsidiaries and affiliates to use the information provided in their selection, initial assessment and reassessment process, and to verify such information as appropriate. I further understand that Independence’s subsidiaries and affiliates have their own criteria for acceptance, and that I may be accepted or rejected by each independently.

(Authorized Signature for Provider)

(Print Name)

(Title)

(Date)

WARRANTY

The information provided in this application and its accompanying documentation may be shared with our subsidiaries and affiliates for assessment and network participation purposes. A subsidiary or affiliate is any corporation or other organization that is or becomes owned or controlled, either directly or through parent corporations, by Independence or under common control with Independence Hospital Indemnity Plan and its affiliates including Keystone Health Plan East (hereinafter referred to collectively as "Independence"). This currently includes the following:

Keystone Health Plan East
Keystone Health Systems
QCC Insurance Company
QCC Insurance Company d/b/a Independence Administrators

ON BEHALF OF THE PROVIDER, I hereby certify that all the information included in this application and the accompanying documents are correct and complete to the best of my knowledge and belief.

If this application contains either (i) any material omissions, or (ii) false or misleading information, participation with Independence may be terminated.
In the event that there are any changes to any of the information provided in this application, Independence will be notified immediately.

I hereby authorize and agree that Independence, its respective agents, employees, and representatives may provide Independence’s subsidiaries and affiliates with any information concerning the organization’s qualifications for the purpose of participation in Independence’s ancillary provider networks. I release Independence, its respective agents, employees, and representatives of any liability for furnishing any such information which is provided in good faith and without malice.

(Authorized Signature for Provider)

(Print Name)

(Title)

(Date)

WARRANTY

The information provided in this application and its accompanying documentation may be shared with our subsidiaries and affiliates for assessment and network participation purposes. A subsidiary or affiliate is any corporation or other organization that is or becomes owned or controlled, either directly or through parent corporations, by Independence or under common control with Independence Hospital Indemnity Plan and its affiliates including Keystone Health Plan East (hereinafter referred to collectively as "Independence"). This currently includes the following:

ON BEHALF OF THE PROVIDER, I hereby certify that all the information included in this application and the accompanying documents are correct and complete to the best of my knowledge and belief.

If this application contains either (i) any material omissions, or (ii) false or misleading information, participation with Independence may be terminated.
In the event that there are any changes to any of the information provided in this application, Independence will be notified immediately.

(Authorized Signature for Provider)

(Print Name)

(Title)

(Date)

Ancillary Credentialing 1.6 20171030

WARRANTY

For those providers that are out of the primary service area, once Independence receives your application, Independence will reach out to you to send the appropriate warranty that has to be signed, dated and returned to Independence.

ON BEHALF OF THE PROVIDER, I hereby certify that all the information included in this application and the accompanying documents are correct and complete to the best of my knowledge and belief.

If this application contains either (i) any material omissions, or (ii) false or misleading information, participation with Independence may be terminated.
In the event that there are any changes to any of the information provided in this application, Independence will be notified immediately.

(Authorized Signature for Provider)

(Print Name)

(Title)

(Date)

Click PRINT, click/double click Adobe PDF and OK to select the file save location.
After saving the application, attach saved application and supporting documentation(as identified in first section of application) and send to: Ancillary Credentialing.

Please complete a separate application for each provider type or service.
Ambulance Ambulatory Care Facility Ambulatory Surgery Center Lithotripsy Center Birth Center Cardiac Monitoring Clinical Laboratory	Durable Medical Equipment Orthotics & Prosthetics Home Health Agency-Adult/Pediatric Home Perinatal Mother's Option Private Duty Nursing Hospice Hospital	Independent Diagnostic Testing Facility Infusion Therapy (Home / Suite) Mobile Radiology Provider Outpatient Diabetic Education Renal Dialysis Center Skilled Nursing Sleep Study

Do you provide services 24 hours per day/7 days per week?	Yes No
Is a qualified person on site 24 hours per day/7 days per week?	Yes No
List all covered services that you provide:

Describe your process to assure ongoing licensure or certification of professional employees (e.g., who monitors the process, how is information maintained, and how frequently is information updated.)

Provider Types and Services

Ancillary Provider Credentialing Application

Physical Address

Additional Office Locations Exist Yes No

Mailing/Correspondence Address (Complete if different from physical address.)

Billing Office/Remittance Address(Complete if different from physical address.)

Corporate/Hospital Affiliation (if applicable)

Medicare

Type of Ownership (Select type of ownership that applies to your organization)

Licensure

Insurance Coverage

Subcontractor Information

Financial Information

Quality Management Program

Ambulance

Number of licensed ambulance vehicles*:

Services:

Medical Service Information:

Staffing:

Provider Arrangements:

Corporate Affiliation:

Ambulatory Care Facility

Staffing:

Transfer Agreements:

Laboratory and Radiology Services:

Ambulatory Surgery Center

Services:

Staffing:

Transfer Agreements:

Laboratory and Radiology Services:

Lithotripsy Center

Services:

Staffing:

Transfer Agreements:

Laboratory and Radiology Services:

Birth Centers

Number of birthing rooms or suites:

Staffing:

Provider Agreements:

Cardiac Monitoring

Clinical Laboratory

Services:

Staffing:

Laboratory Tests:

Provider Specific Information — Comprehensive Outpatient Rehab Facility

Services:

Staffing:

Durable Medical Equipment

Services:

Staffing:

Orthotics/Prosthetics

Services:

Staffing:

Home Health Agency

Service Types:

Services:

Staffing:

Hours of operation–Indicate hours and days of the week provide services:

Home Perinatal:

Specialty Services (Check all services that you provide):

Staffing (Provide the number of the following providers on staff):

Mother's Option Postnatal Program:

Postnatal Services*

Staffing (Provide the number of the following providers on staff):

Private Duty Nursing

Services:

Staffing:

Independent Diagnostic Testing Facility

Type of Diagnostic Testing Facility:

Services (Check all that your facility provides):

Staffing:

Infusion Therapy (Suite / Home)

Additional Requirements

Staffing:

Hospice

Type of hospice:

Services:

Staffing (Provide the number of the following providers on staff):

Medical Director (Physician):

Hospital