The North Carolina Department of Insurance Uniform Application is a necessary form for health care practitioners seeking to participate in health benefit plans. This form is designed to ensure that all applicants provide the required information for credentialing by insurers, as mandated by North Carolina law. To get started on your application, click the button below.
The North Carolina Department of Insurance Uniform Application to Participate as a Health Care Practitioner is a crucial document for health care providers seeking to join an insurer's network. This form, mandated by North Carolina General Statute 58-3-230, ensures that every insurer offering health benefit plans adheres to a standardized process when credentialing providers. It is essential for applicants to fill out every section of the form completely, using "N/A" for any questions that do not apply to their situation. The application requires various supporting documents, including copies of state licenses, current registrations, and proof of professional liability insurance. Additionally, applicants must provide demographic and personal data, detailing their practice type, areas of clinical expertise, and office locations. The form also includes sections for listing other providers in the practice and arrangements for 24-hour coverage, reflecting the collaborative nature of health care. It is important to remember that only the Commissioner of Insurance has the authority to modify this form, ensuring its integrity and consistency across the board. Completing this application accurately is vital for health care practitioners aiming to provide their services effectively within North Carolina's health care system.
North Carolina Department of Insurance
Uniform Application
To Participate as a Health
Care Practitioner
Note: Please send completed applications directly to the
organizations with which you seek to contract.
The following application is a form approved by the North Carolina Department of Insurance, in accordance with North Carolina General Statute 58-3-230. Every insurer that provides a health benefit plan and credentials providers for its network is required to use this form and the insurer may not require an applicant to submit information that is not required by this form Only the Commissioner of Insurance is authorized to make changes, deletions or additions to this form.
June 2005
Page 1
INSTRUCTIONS
Before submitting the Application, make sure you have completed the following: Include an answer in all spaces. Indicate "N/A", if the question is not applicable. The provider has signed and dated the last page of the Application.
Before submitting the Application, make sure you have enclosed the following, if applicable: Copy of the provider's original state(s) license(s) and current registration.
Copy of current DEA certificate. (Must have a valid date and refer to current address.) Copy of South Carolina Controlled Drug Substance Certificate and DEA information.
Copy of the face sheet of your current professional liability insurance policy, indicating by name, provider(s) covered, coverage amounts, effective date, expiration date, and policy number. Attach previous carrier face sheet.
Proof of professional liability insurance for non-physician providers who care for patients in your practice. Copy of certificate from the Specialty Board.
Copy of Educational Commission of Foreign Medical Graduate Certificate- ECFMG. Letter(s) of reference, recommendation, and/or oversight, if required.
Copy of Curriculum Vitae or work history after graduation from Medical, Dental or other professional school
(CV must account for any gaps of 90 days or more).
Copy of CLIA (Clinical Laboratory Improvement Amendments) /ACR (American College of Radiology). Copy of W-9 Form.
Examples of documentation to attach to this application:
Page 2
A.DEMOGRAPHIC AND PERSONAL DATA:
1.
2.
3.
4.
5.
Name of Applicant:
(Last Name)
(First Name)
(Middle Name)
(Maiden)
Date of Birth:
Place of Birth:
Social Security Number:
Sex:
Male
Female
Type of Practice:
Primary Care:
Specialist:
(Primary Specialty)
(Secondary Specialty)
Please Identify Areas of Clinical Expertise:
What population(s) do you treat (e.g. geriatric, all ages):
Name of Practice:
Primary Office Address (If you maintain more than one office, list each office, address, and hours of operation)
Practice Name:
Address:
(Street)(City)(County) (State) (Zip)
Handicapped Accessible?
YES
NO
Office Phone:
Fax:
E-mail address:
Accepting New Patients?
Restrictions:
(Please list or indicate none)
Office Hours:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Secondary Office Address
Page 3
A. DEMOGRAPHIC AND PERSONAL DATA (Continued)
Additional Office Address or Billing Address, if different (check one)
Billing
Office
Name:
Office Phone: xxx-xxx-xxxx/xxxx
Fax: xxx-xxx-xxxx/xxxx
6.Name other provider(s) in your practice (if not enough space, please attach additional sheet):
7.Do nurse practitioners, physician assistants, midwives, social workers, or other non-physician providers provide care to
patients in your practice?
(If yes, please attach proof of professional liability insurance and proof of employment for those individuals)
8.
Name and address of provider(s) who share call with you (if not enough space, please attach additional sheet):
9.
10.
Arrangements for 24 hour/7 day coverage:
Administrative Contact:
(Title)
xxx-xxx-xxx/xxxx
(Name)
(Telephone)
11.IRS requires reimbursement be made payable to name of practice affiliated with Federal Tax ID Number:
Federal Tax ID Number:
Name (if different from practice name):
Billing Address (if different from practice address):
12.
13.
UPIN Number:
Medicare/Medicaid Number:
/
National Provider Identifier (NPI):
DEA Number:
Exp. Date:
(Attach copy to application)
Page 4
A.DEMOGRAPHIC AND PERSONAL DATA (Continued)
COMPLETE ONLY IF LICENSED IN SOUTH CAROLINA
SC Controlled Drug Substance Certificate:
Expiration Date:
(Attach a copy to application)
14.
Provide the following information for each state in which you are currently or were previously licensed to Practice (If not enough space please attach additional sheet)
STATE
DATE OF LICENSE
LICENSE NUMBER
STATUS
EXPIRATION
Active, Inactive, Suspended
DATE
PLEASE ATTACH A COPY OF EACH STATE LICENSE CERTIFICATE
15.
Certification of Specialty Boards as applicable:
a.If you are certified by a specialty board, indicate name of board and date of certificate.
Date Certified:
(Primary Specialty Board)
(Secondary Specialty Board)
b..
Are you listed in the American Board of Medical specialists? YES
c.If you have applied to a specialty board for examination, give the name of board and the date of scheduled examination. Date:
d. If you have not applied to a specialty board, please explain:
Page 5
16.
List the dates of all current professional memberships in societies, including state and county societies:
FROMTO
17.
List all hospitals where you currently have privileges and indicate the type and status of those privileges:
(Type: active, admitting, associate, consulting, courtesy.
Status: pending, provisional, suspended, temporary, visiting)
Hospital
Privilege and Status of Privilege
Estimated % of Admission
(primary admitting facility)
18.
If you do not have admitting privileges, who admits for you?
Name:Name:
Address:Address:
Phone:
Page 6
B.EDUCATION AND PRACTICE HISTORY
Medical, Dental, or other Professional School Attended:
Institution:
(Street)
(City)
(State)
(Zip)
Degree:
From:
To:
Please attach Educational Commission of Foreign Medical Graduate Certificate – (ECFMG), if applicable.
Internship
Specialty:
From: xx/xx/xxxx
xx/xx/xxxx
Residency
Other Residency / Fellowship – (specify)
Page 7
B. EDUCATION AND PRACTICE HISTORY (Continued)
6.
7.
List work history since beginning of medical, dental, or other professional school; please be specific.
(If not enough space, please attach additional sheet)
(Current Practice)
(Previous Practice)
List other training and/or education (including CME) within the last three years, if applicable.
Have you involuntarily or voluntarily withdrawn or been suspended from any internship, residency or fellowship training program? Please explain:
Please explain any incident(s) in which you have involuntarily or voluntarily withdrawn your application for appointment, clinical privileges or reappointment before a decision was made by a hospital or healthcare facility’s governing board.
Page 8
C.PROFESSIONAL INFORMATION
Please check yes or no for the following questions. Please complete the attached Supplemental Form for any questions to which you answer “yes”. Also please sign and date this application. If this application does not have the provider’s signature, it cannot be accepted.
Has your license to practice in any jurisdiction ever been limited, restricted, reduced, suspended,
Y
N
voluntarily surrendered, revoked, denied or not renewed; have you ever been reprimanded by a state
licensing agency; or are any of these actions pending with respect to your license; are you under
investigation by any licensing or regulatory agency? (If yes, please complete Supplemental Question
No. 1.)
Has your professional employment or membership in a professional organization ever been subject
to disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed,
or voluntarily relinquished during or under threat of termination for any reason? (If yes, please
complete Supplemental Question No.2.)
Has your Drug Enforcement Agency registration or other controlled substance authorization ever
been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily
surrendered or limited your registration during or under the threat of an investigation or are any
such actions pending? (If yes, please complete Supplemental Question No.3.)
Have you ever been sanctioned or suspended by Medicare or Medicaid? (If yes, please complete
Supplemental Question No.4.)
To your knowledge, have you ever been reported to the National Practitioner Data Bank or the
North/South
Carolina Board of Medical Examiners? (If yes, please complete Supplemental Question No.5.)
Have you ever been convicted of a felony or misdemeanor, or are you under investigation with
respect to such conduct? (If yes, please complete Supplemental Question No.6.)
Has a professional liability claim been assessed against you in the past five years, or are there any
professional liability cases pending against you? (If yes, please complete Supplemental Question
No.7.)
Has any liability insurance carrier canceled, refused coverage, or rated up because of unusual risk or
have any procedures been excluded from your coverage? (If yes, please complete Supplemental
Question No. 8.)
Have you ever practiced without liability coverage? (If yes, please complete Supplemental Question
No.9.)
Do you currently have any medical, chemical dependency or psychiatric conditions that might
adversely affect your ability to practice medicine or surgery or to perform the essential functions of
your position? (If yes, please complete Supplemental Question No.10.)
11.
Have your Hospital and/or Clinic privileges ever been limited, restricted, reduced, suspended,
revoked, denied, not renewed, or have you voluntarily surrendered or limited your privileges during
or under the threat of an investigation or are any such actions pending? (If yes, please complete
Supplemental Question No. 11).
Page 9
SUPPLEMENTAL FORM
Provider Name:
Provider ID#
(if applicable)
1. License Limited, Reprimanded, etc.
List State(s) where action took place:
Date(s) License revoked, suspended, etc.
From xx/xx/xxxx
To xx/xx/xxxx
Please explain:
2. Employment/Membership Suspended, Limited, etc.
List Professional Organization:
3. Drug Enforcement Agency (DEA) Explanation.
Page 10
Follow these steps to complete the North Carolina Department of Insurance form accurately. Ensure that all required information is filled out and that any necessary documents are attached before submission.
After completing the form, review all entries for accuracy. Ensure that you have signed and dated the last page. Collect any required documents, such as licenses and insurance certificates, to include with your application. Submit the completed application directly to the organizations you wish to contract with.
The North Carolina Department of Insurance Uniform Application is designed for health care practitioners who wish to participate in health benefit plans. This form ensures that all necessary information is collected in a standardized manner, facilitating the credentialing process by insurers. It is a requirement under North Carolina General Statute 58-3-230.
Every insurer that offers a health benefit plan in North Carolina must utilize this form when credentialing health care providers for their network. This requirement helps maintain consistency and compliance across the state's health care system.
Prior to submission, ensure that you have completed all sections of the application. If a question does not apply to you, indicate "N/A." Additionally, verify that the last page of the application is signed and dated. It is also important to gather and attach any required documentation, such as copies of licenses, certificates, and proof of insurance.
Depending on your practice, you may need to include several documents, such as:
Ensure that each document is current and relevant to your practice.
No, only the Commissioner of Insurance has the authority to make changes to the application form. It is crucial to use the form as it is provided to ensure compliance with state regulations.
If you are a non-physician provider, you still need to complete the application and provide proof of professional liability insurance. This ensures that you meet the necessary standards for credentialing within the health care network.
Once you have completed the application and attached all necessary documentation, submit it directly to the organizations with which you wish to contract. Do not send the application to the North Carolina Department of Insurance.
Failing to provide answers in all required spaces. Every section of the form must be completed, even if the answer is "N/A".
Neglecting to sign and date the last page of the application. The applicant's signature is necessary for the application to be valid.
Not including the necessary documentation. Missing items, such as copies of licenses or proof of insurance, can lead to delays.
Providing outdated or incorrect information. Ensure that all details, especially contact information and licenses, are current.
Overlooking the requirement for proof of professional liability insurance. Non-physician providers must also include this documentation.
Failing to list all office addresses and hours of operation. If multiple offices are maintained, each must be detailed.
Not indicating whether the office is handicapped accessible. This information is important for compliance and patient accessibility.
Forgetting to include names of other providers in the practice. This information is essential for understanding the practice structure.
Not attaching proof of employment for non-physician providers. If applicable, this documentation must accompany the application.
When applying to participate as a health care practitioner in North Carolina, it’s essential to have several supporting documents ready. These documents help streamline the application process and ensure compliance with state regulations. Below are some key forms and documents commonly used alongside the North Carolina Department of Insurance form.
Gathering these documents not only supports your application but also demonstrates your commitment to meeting the standards required for participation as a health care practitioner. Being thorough and organized can significantly improve your chances of a smooth application process.
The North Carolina Department of Insurance Uniform Application shares similarities with the National Practitioner Data Bank (NPDB) self-query form. Both documents are designed to collect essential information about healthcare practitioners. The NPDB form requires practitioners to provide personal details, including their professional qualifications and any disciplinary actions taken against them. Like the North Carolina application, the NPDB form aims to ensure that healthcare providers meet specific standards and are credentialed appropriately before being allowed to practice in a network or facility.
Another comparable document is the Credentialing Application used by various hospitals and health systems. This application serves a similar purpose in verifying a healthcare provider's qualifications, background, and experience. The Credentialing Application typically requires detailed information about education, training, and professional experience, paralleling the requirements of the North Carolina Department of Insurance form. Both documents facilitate the credentialing process, which is crucial for maintaining patient safety and quality of care.
The American Medical Association (AMA) also provides a Physician Application for Membership that resembles the North Carolina form. This application collects demographic data, educational background, and professional experience from applicants seeking membership in the AMA. Both documents emphasize the importance of accurate and complete information to uphold standards within the healthcare profession. The AMA application, like the North Carolina form, may require supporting documents such as proof of licensure and insurance coverage.
Furthermore, the state licensing application for healthcare practitioners aligns closely with the North Carolina Department of Insurance form. Licensing applications generally require similar demographic and professional information, including educational qualifications and proof of current licensure. Both documents aim to ensure that practitioners meet the necessary legal and professional requirements to provide healthcare services within their respective states.
Lastly, the Medicare Enrollment Application for Physicians and Non-Physician Practitioners is another document with significant similarities. This application collects essential information to enroll healthcare providers in the Medicare program. Similar to the North Carolina application, it requires details about the provider’s practice, including demographic information, credentials, and insurance details. Both forms serve to verify that healthcare providers are qualified to deliver services to patients and comply with regulatory standards.
When completing the North Carolina Department of Insurance form, it is essential to approach the task with care and attention. Below is a list of recommendations to guide you through the process effectively.
By following these guidelines, you can ensure that your application is complete and stands the best chance of being processed without unnecessary delays. Your diligence in this matter reflects your commitment to providing quality care.
Understanding the North Carolina Department of Insurance form is crucial for health care practitioners. However, several misconceptions can lead to confusion. Here are eight common misunderstandings, along with clarifications.
By addressing these misconceptions, health care practitioners can navigate the application process more effectively and ensure they meet all necessary requirements.
Filling out the North Carolina Department of Insurance form is an important step for health care practitioners seeking to participate in health benefit plans. Here are some key takeaways to keep in mind:
By following these guidelines, you can navigate the application process more smoothly and increase your chances of successful participation in health benefit plans.