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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.)

Do you limit the age of patients you treat?

If yes, what ages do you treat?

Yes No

Minimum: Maximum:

Remittance/Billing Information

(NOTE:  Must match box 33 on HCFA/CMS 1500)

Are all services payable to one practice or group name/address?

Yes No

Group/Practice Name (Check Payable To):

Address (Building, Street, Suite #)

City

State

Zip Code

Billing Office Telephone Number

Billing Manager’s Name

(   )    -

Tax ID Number (must match W-9)

Name affiliated with Tax ID Number (must match W-9)

Business Interests

Do you or your business entity own, operate, have an interest in, or participate in any medical enter­prise or business?

Yes No

If yes, provide details on separate sheet.

Do you have a financial relationship with a hospital, clinical lab, nursing home, pharmacy, radiology lab, emergency room, or any other medical related organization?

Yes No

If yes, provide details on separate sheet.

Practice Classification

Primary Care Physician (Family Practitioners, Internists, or Pediatricians who deliver primary health care services)

Specialist Physician (Physicians other than primary care physicians in their designated clinical practice)

Allied Health Professional (Licensed, certified, or registered non-physician practitioners of direct patient care services)

Dual Role (Serve as both a Primary Care Physician as well as a Specialist)

Directory Listing

Should this office be listed in the directory?

Should this office receive correspondence?

Yes No

Yes No

Please indicate, in preference order, how you wish to be listed in the directory.

Primary Specialty:  

Secondary Specialty:  

After-Hours Coverage

Do you provide 24-hour coverage?

Describe Coverage

Yes No NA

Do you have an answering service/machine?

Is your answering service/machine available

at all times when you are not in the office?

Yes No NA

Yes No NA

List below other after-hours arrangements or special instructions to patients for after-hours care needs:

Back-up Coverage

(Please list the name, specialty, and telephone number of partner(s) or associate(s)

or physician(s) covering your practice in your absence.)

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 4

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