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State of West Virginia Recredentialing Form:  Misrepresentation of any statements and information provided by you in support of this application shall be considered fraudulent and may result in denial or revocation of appointment.  (If more space is needed, please supply the information on a separate sheet and attach.)

2.Office Practice Information: (Complete only for information changed since last date of credentialing)

 Check if entire section unchanged since last date of credentialing

If you have more than one office site or more than one billing address or entity, please make a photocopy of this section before completing it and provide information for each site or billing entity (i.e., multiple tax identifiers), as needed. Indicate below whether the office is the primary or an additional site.  (NOTE:  Only one primary site should be designated.)

Primary Office Site # 1

Additional Office Site #

Group/Practice Name

Type of Practice

 Individual

 Partnership

 Group

 Corporation

 Hospital Based

 Teaching or Research

 Other (specify):  

Address (Building, Street, Suite #)

City

State

Zip Code

County

Telephone Number

Fax Number

Answering Service/After-Hours Number

(   )    -

(   )    -

(   )    -

Alternate Telephone Number

Cell Phone Number

Beeper/Pager Number

(   )    -

(   )    -

(   )    -

E-Mail Address

Long Range Beeper Number

(   )    -

Medicare Number

UPIN Number

Medicaid Number

Are you currently accepting new patients?

Have you closed your practice to any plans or programs?

Yes         By referral only No       NA

Yes No NA

If Yes, please list:  

Handicap Accessible?

Public Transit Available?

Yes No NA

Yes No NA

Does the office have other services available for disabled?

(TTY, ASI, Mental/physical impairments, etc.)

If yes, list below what services are available

Yes No NA

Office Manager’s Name

Nurse Manager’s Name

Credentialing Contact

N/A

N/A

Name     N/A

Phone #  

Office Hours ____

Check if not applicable        Check if  practitioner is not available to see patient during hours indicated

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

AM  

PM  

AM  

PM  

AM  

PM  

AM  

PM  

AM  

PM  

AM  

PM  

AM  

PM  

Services Provided
(Please check below if these services are available)

Lab Services

On-Site

Reference Lab Name:

CLIA Number and Type of Certification:

Radiology Services

EKG

Sigmoidoscopy

Audiology Services

Treadmill

Other (Please list):  

List any special diagnostic or treatment procedures performed in your office:  

Patient Population

12/02; 3/03; 11/03; 1/04; 5/04; 10/04     **Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq** Page 3

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