JoinNetworkForm

Basic Information

Contact Name*:

Phone Number*:

Email Address*:

Pay to Provider Name*:

Rendering Provider Name*:

Provider Specialty*:

Are you a member with Acuplan Hawaii?*

Yes No

Are you a member of ChiroPlan?*

Yes No

Office Location*:

Basic Information Continued

Date of Birth*:

TIN Number*:

Rendering NPI*:

Pay-To NPI*:

When did you finish training? What have you been doing since?

Please provide information on clinical experience and where clinical rotations occurred?

Does the provider applying have any gaps in employment history that are greater than six months?*

Yes No

If Yes, please explain:

Additional Questions

How many hours of post-graduate training do you have?*

In UHA’s efforts to exceed mental health parity requirements, we are asking the following questions for providers in this area.

What is the percentage of telehealth that is anticipated?*

What is the training for prescribing of medication?*

If a member needs or wants to have a face-to-face encounter, what arrangements are in place to facilitate that request?*

If a member needs an advanced level of care, are there escalation procedures in place to service their needs beyond sending them to an emergency room? (this includes referral to other providers for complicated diagnoses, do they have an in person or higher level of care provider they are working with?*

Yes No

If Yes, please elaborate on your procedures and providers you are working with:

Who is your supervising/monitoring physician?*

Name*:

Phone number*:

I certify that I have read, understand, and will fully comply with UHA's APRN/PA Payment Policy.

Location

Are you licensed to practice in the state of Hawaii?*

Yes No

Are you accepting new patients?*

Yes No

Physical Locations*:

PHYSICAL LOCATION ADDRESS(ES) for Provider’s Medical Office(s)	CONTACT INFORMATION	PAY TO/REMITTANCE MAILING ADDRESS
1. Primary Location Address City State Zip	Office Telephone: Fax Number: Handicap Accessible Post location on UHA Provider Directory	Primary Location Address City State Zip
2. Additional Location Address City State Zip	Office Telephone: Fax Number: Handicap Accessible Post location on UHA Provider Directory	Additional Location Address City State Zip
3. Additional Location Address City State Zip	Office Telephone: Fax Number: Handicap Accessible Post location on UHA Provider Directory	Additional Location Address City State Zip

Practice Information

Define the Scope of your Practice:

Are you a PCP or Specialist?

Are you a Hospitalist?

Yes No

List the services you intend to provide:

(For MD’s & DO’s who have the specialties family practice, internal medicine, or geriatrics only) Will Provider be working for a Skilled Nursing Facility or Nursing Home? If so, what services will be provided?

Will you practice full or part time?

Full-time

Part-time

(For MD’s & DO’s only) Will you be locum or permanent?

Locum

Permanent

What is your anticipated start date?

Provide 3 Peer References* :

Contact Name*: Phone Number*: Email Address*:

Restrictive Actions Questions

List your professional liability insurance carrier, including policy coverage limits per incident and aggregate:*

Are you currently a named defendant to any pending malpractice claim or suit?*

Yes No

Have you ever been a named as a defendant in any malpractice claim or suit where judgment was made against you or where you settled out of court with the plaintiff?*

Yes No

Restrictive Action Additional Information

Please complete the following questions since you've answered "Yes" to any of the Restrictive Actions questions above. Complete a separate form for each pending or closed professional adverse action whether or not any payment was made on your behalf. All questions must be answered completely. If additional sheets are required, please indicate below.

Provider Name:*

Date of Incident:*

Description of occurrence:*

Outcome:*

Resolved

Pending

Please provide details about the circumstances related to this occurrence:*

Please describe the extent of your involvement and actions related to the occurrence:*

Please articulate any professional insights from your perspective about the occurrence. What process improvements, if any, have you made in your professional practice to prevent a similar incident from occurring in the future?*

If you believe that your actions were appropriate despite any adverse occurrence/actions, please provide an explanation and supporting documents. (E.g., MCCP decision documents, Stipulation for Dismissal without a settlement, independent expert professional opinions, etc.):*

Do you have more incidents?*

Yes

Required Documents

The maximum file size for uploads is 8 MB per file.
Allowed file types: PDF, JPEG, GIF, BMP, TIFF and PNG
UHA requires submission of all the documents listed below to approve your request

CV*:

License*:

Board Certification*:

W9*:

DEA (If appliable):

Provider Enrollment Application Form: Please complete all steps to submit the form.

Basic Information

Basic Information Continued

Additional Questions

In UHA’s efforts to exceed mental health parity requirements, we are asking the following questions for providers in this area.

Location

Board Certifications

Practice Information

Restrictive Actions Questions

Restrictive Action Additional Information

Required Documents