Mississippi PDF Forms
Homepage ⇨ Download Mississippi Participating Application Form
Jump Links

The Mississippi Participating Application form is a comprehensive document designed for physicians who wish to apply or reapply for participation in a managed care entity within the state. This detailed form captures a wide array of information essential for the evaluation of a physician's eligibility and qualifications for participation. It covers sections such as practice, educational background, licensure, work history, and more. Physicians are instructed to fill out the application in black ink or type it, ensuring readability and avoiding abbreviations for clarity. The form requires applicants to include current copies of critical documents like state medical licenses, DEA certificates, proof of professional liability insurance, detailed curriculum vitae, board certification (if applicable), and, for foreign-trained physicians, the ECFMG certificate. Additionally, it delves into practice information, including office locations, accessibility features, willingness to accept new patients, and coverage for after-hours care. Also notable is the emphasis on not only the primary but also the secondary and tertiary practice locations, indicating a comprehensive approach to understanding a physician's reach and accessibility. With specific sections dedicated to billing information, office hours, coverage plans, languages spoken by the physician and staff, and even the types of anesthesia provided in the office, the application form is tailored to ensure that all pertinent aspects of a physician's practice are disclosed. This thorough vetting process is indicative of the stringent measures in place to maintain high standards of medical care in the Mississippi managed care system.

Example - Mississippi Participating Application Form

 

CONFIDENTIAL/PROPRIETARY

Please check one:

Mississippi Participating Physician

Original Application

Application

Reappointment

This application is submitted to:_______________________________, herein, this Managed Care Entity 1.

SECTION A.

Practice, Educational, Licensure and Work History Information

I. INSTRUCTIONS

This form should be typed or legibly printed in black ink. If more space is needed than provided on original, attach additional sheets and reference the questions being answered. Please do not use abbreviations when completing the application. If an item in the application does not apply to you, write N/A in the box provided. Current copies of the following documents must be submitted with this application.

z State Medical License(s)

z Face Sheet of Professional Liability Policy or Certification

z DEA Certificate

z Curriculum Vitae

z Board Certification (if applicable)

z ECFMG (if applicable)

II. IDENTIFYING INFORMATION

Last Name:

First:

Middle:

Is there any other name under which you have been known (AKA/Maiden Name)? Name(s):

 

Home Mailing Address:

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Telephone Number:

 

 

 

 

 

 

E-Mail Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Fax Number:

 

 

 

 

 

 

Pager Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birthday Date:

 

 

 

Birth Place (City/State/Country):

 

Citizenship (If not a United States citizen, please include a copy of

 

 

 

 

 

 

 

 

 

 

 

 

 

Alien Registration Card).

 

 

 

 

 

 

 

 

Social Security #:

 

 

 

 

 

 

 

 

 

 

Gender 2 :

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race/Ethnicity 2

 

 

 

 

 

 

 

 

 

Specialty:

 

 

 

 

 

 

 

 

 

 

(voluntary):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Subspecialties:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Internal Medicine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. PRACTICE INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Practice Name (if applicable):

 

 

 

 

 

Department Name (if Hospital based):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Office Street Address:

 

 

 

 

 

Primary Office Mailing Address if different from Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

State:

County:

Zip:

 

City:

 

 

State:

 

 

County:

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

FAX Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Manager/Administrator:

 

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name Affiliated with Tax ID Number:

 

 

 

 

Federal Tax ID Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1As used in the information Release/Acknowledgements Section of this application, the term “this Managed Care Entity” shall refer to

the entity to which the application is submitted as identified above.

2 This information will be used for consumer information purposes only.

 

Mississippi Participating Physician Application – 11/99

Page 1 of 12

 

Secondary Office Street Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Manager/Administrator:

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAX Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name Affiliated with Tax ID Number:

Federal Tax ID Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tertiary Office Street Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Manager/Administrator:

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAX Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name Affiliated with Tax ID Number:

Federal Tax ID Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Handicap Access:

 

 

 

 

24 Hour Coverage:

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

Yes

 

No

 

Will you accept new patients?

 

 

 

 

Back office Telephone Number:

 

 

 

 

 

 

 

Yes

No

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please identify other networks in which you participate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please identify other networks from which you have been denied admission or de-selected:

 

 

 

 

 

 

 

Name of Network

 

 

Address

 

 

 

 

 

 

 

 

Reason for Denial or Deselection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have ownership in any health or medical related organization, e.g., laboratory, home health care agency, radiology facility,

lithotrips, mobile testing, MRI, etc?

Yes

No

 

 

 

 

 

 

If Yes, please list:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Group(s) / IPA(s) Affiliation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you intend to serve as a primary care provider?

Yes

No

Please check all that apply:

 

 

 

 

Do you intend to serve as a specialist?

 

Yes

No

Solo Practice

Single Specialty

If Yes, please list specialty(s):

 

 

 

Group Practice

Multi Specialty

 

 

Do you employ any allied health professionals (e.g. nurse practitioners, physician assistants, psychologists, etc.)?

Yes

No

If so, please list:

 

 

 

 

 

 

 

 

Name:

 

 

Type of Provider:

 

License Number:

______________________________________ _______________________________________________________________________

______________________________________ __________________________________________________ _____________________

______________________________________ ___________________________________________________ _____________________

Do you personally employ any physicians? (Do Not include physicians that are employed by the medical group)

Yes

No

Name:

Mississippi Medical License Number:

 

 

 

_________________________________________________________________

 

_____________________________________________

 

 

 

_________________________________________________________________

 

_____________________________________________

 

 

_________________________________________________________________

 

____________________________________________

 

 

 

 

 

 

 

Mississippi Participating Physician Application – 11/99

Page 2 of 12

Please list any clinical services you perform that are not typically associated with your specialty:

Please list any clinical services you do not perform that are typically associated with your specialty:

 

 

Is your practice limited to certain ages?

 

 

 

If Yes, specify limitations:

 

 

 

 

 

 

 

 

 

Yes

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you participate in EDI (electronic date interchange)?

Yes

No

 

 

Do you use a practice management system/software: Yes

No

 

 

If so, which Network?

 

 

 

 

 

 

 

 

 

If so, which one?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What type of anesthesia do you provide in your group/office?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Local

Regional

Conscious Sedation

 

General

 

 

None

Other (please specify):

___________________

 

 

 

Has your office received any of the following accreditation’s, certifications, or licensures?

 

 

 

 

 

 

 

 

 

 

 

American Association for Accreditation of Ambulatory Surgery Facilities (AAASF)

Medicare Certification

 

 

 

 

 

Mississippi Department of Health Licensure

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IV. BILLING INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Billing Company:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact:

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name Affiliated with Tax ID Number:

 

 

 

 

 

 

 

 

Federal Tax ID Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V. OFFICE HOURS – Please indicate the hours your office is open:

Monday

Tuesday

Wednesday

Thursday

Friday

 

24 HOUR

24 HOUR

24 HOUR

24 HOUR

24 HOUR

 

COVERAGE

COVERAGE

COVERAGE

COVERAGE

COVERAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Saturday

24HOUR COVERAGE

Sunday

24HOUR COVERAGE

Holidays

24HOUR COVERAGE

VI. COVERAGE OF PRACTICE (List your answering service and covering physicians by name. Attach additional sheets if necessary. Reference this section number and title)

Answering Service Company:

Telephone Number: ( )

Fax Number: ( )

 

Mailing Address:

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Covering Physician’s Name:

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Covering Physician’s Name:

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Covering Physician’s Name:

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Covering Physician’s Name:

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you do not have hospital privileges, please provide written plan for continuity of care:

Mississippi Participating Physician Application – 11/99

Page 3 of 12

VII. FOREIGN LANGUAGES SPOKEN

 

 

 

 

 

 

 

 

 

Fluently by Physician:

 

 

Fluently by Staff:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VIII. LABORATORY SERVICES

If you provide direct laboratory services, please indicate the TIN utilized and provide Clinical Laboratory Information Act (CLIA) information. Attach a copy of your CLIA certificate or waiver if you have one.

 

Tax ID #:

Billing Name:

 

 

 

 

 

 

 

 

 

Type of Service Provided:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have a CLIA Certificate?

 

 

 

 

 

 

 

Do you have a CLIA waiver?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certificate Number:

 

 

 

 

 

 

 

 

 

Certificate Expiration Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IX. MEDICAL/PROFESSIONAL EDUCATION

(Attach additional sheets if necessary. Reference this

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

section number and title.)

 

 

 

Medical School:

 

 

 

 

 

 

 

 

 

 

 

Degree Received:

 

 

 

 

Date of Graduation (mm/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State & Country:

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical/Professional School:

 

 

 

 

 

 

 

 

Degree Received:

 

 

 

 

Date of Graduation (mm/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State & Country

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X.

INTERNSHIP/PGYI (Attach additional sheets if necessary, Reference this section number and title.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Institution:

 

 

 

 

 

 

 

 

 

Program Director:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State & Country:

 

 

 

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Internship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specialty:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From: (mm/yy)

 

To: (mm/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XI.

RESIDENCES/FELLOWSHIPS (Attach additional sheets if necessary. Reference this section

number and title.)

Include residencies, fellowships, preceptorships, teaching appointments (indicate whether clinical or academic). And postgraduate education in chronological order, giving name, address, city, state, country, zip code and dates. Include all programs you attended, whether or not completed.

 

Institution:

 

 

 

 

 

Program Director:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State & Country:

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Training (e.g. residency, etc)

 

Specialty:

 

 

 

 

 

From: (mm/yy)

 

To: (mm/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you successfully complete the program?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No (If “No”, please explain on separate sheet.)

 

 

 

 

 

 

 

 

 

 

Mississippi Participating Physician Application – 11/99

 

 

 

 

 

 

 

 

 

 

 

 

Page 4 of 12

Institution:

 

Program Director:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State & Country:

ZIP:

 

Type of Training (e.g. residency, etc)

Specialty:

 

 

 

 

 

 

 

From: (mm/yy)

 

To: (mm/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you successfully complete the program?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

(If “No”, please explain on separate sheet.)

 

 

 

 

 

 

 

 

Institution:

 

 

 

 

 

 

 

Program Director:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Training (e.g. residency, etc)

 

Specialty:

 

From: (mm/yy)

 

To: (mm/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you successfully complete the program?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

(If “No”, please explain on separate sheet.)

 

 

 

 

 

 

 

XII. BOARD CERTIFICATION (Attach copies of documents.)

Include certifications by board(s) which are duly organized and recognized by: z a member board of the American Board of Medical Specialties

z a member board of the American Osteopathic Association

z a board or association with an Accreditation Council for Graduate Medical Education of American Osteopathic Association approved post graduate training that provides complete training in that specialty or subspecialty.

 

Name of Issuing Board:

 

 

 

Specialty:

 

 

Certification Number:

 

Date Certified/ Rectified:

 

 

Expiration Date (if any):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you applied for board certification other than those indicated above?

Yes No

If so, list board(s) and date(s):

If not certified, describe your intent for certification, if any, and date of admissibility for certification on separate sheet.

Have you taken or failed a board exam?

 

If Yes, Provide details.

Yes

No

 

XIII. OTHER CERTIFICATIONS (e.g. Fluoroscopy, Radiography, etc.) (Attach additional sheets if necessary.

 

 

 

 

 

Reference this section number and title.)

Type:

 

 

 

Number:

 

 

 

Expiration Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type:

 

 

 

Number:

 

 

 

Expiration Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XIV. MEDICAL LICENSURE/REGISTRATIONS (Attach copies of documents)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mississippi State Medical License Number:

 

Issue Date:

 

Expiration Date:

Active:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

Drug Enforcement Administration (DEA) Registration Number:

 

 

 

Expiration Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unlimited?

Yes

No If “No”, please explain on separate sheet

 

 

 

 

 

 

 

 

 

 

Controlled Dangerous Substances Certificate (CDS) (if applicable):

 

 

 

Expiration Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mississippi Participating Physician Application – 11/99

 

 

 

 

 

Page 5 of 12

 

 

ECFMG Number (applicable to foreign medical graduates):

Visa Number:

 

 

Date Issued:

 

Valid Through:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Issued:

 

Valid Through:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare UPIN/National Physician Identifier (NPI):

Mississippi Medicare Number:

Mississippi Medicaid Number:

XV. ALL OTHER STATE MEDICAL LICENSES – List all Medical licenses now or Previously Held. (Attach additional sheets if necessary. Reference this section number and title.)

State

State:

State:

License Number:

 

Expiration Date:

Active:

 

 

 

 

 

 

Yes

No

License Number:

 

Expiration Date:

Active:

 

 

 

 

 

 

Yes

No

License Number:

 

Expiration Date:

Active:

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XVI. PROFESSIONAL ORGANIZATIONS

Please list county, state or national medical societies, or other professional organizations or societies of which you are a member or applicant.

ORGANIZATION NAME

Applicant

Member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you an Officer or Director of any of the professional organizations listed above?

 

 

If Yes, please list:

Yes

No

XVII. PROFESSIONAL LIABILITY (Attach copy of professional liability policy or certification face sheet.)

Current Insurance Carrier:

Policy Number:

Original effective date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State & Country:

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

( )

 

 

 

 

 

 

( )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Per Claim Amount: $

 

 

 

Aggregate Amount: $

 

 

 

 

 

 

 

Expiration Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please explain any surcharges to your professional liability coverage on a separate sheet. Reference this section number and title.

If you have had professional liability carriers in the last five years other than the one listed above, please list them below.

 

Name of Carrier:

Policy # :

 

From: (mm/yy)

 

To: (mm/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State and Country::

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Carrier:

 

Policy # :

 

From: (mm/yy)

 

To: (mm/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State and Country:

ZIP:

Mississippi Participating Physician Application – 11/99

Page 6 of 12

 

Name of Carrier:

Policy # :

 

From: (mm/yy)

 

To: (mm/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State & Country:

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Carrier:

 

Policy # :

 

 

From: (mm/yy)

 

 

To: (mm/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State & Country:

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XVII. CURRENT HOSPITAL AND OTHER INSTITUTIONAL AFFILIATIONS

Please list in (A) in reverse chronological order, with the most current affiliation(s) first, all institutions with which you are currently affiliated. List previous affiliations during the past ten years in (B). Include hospitals, surgery centers, institutions, corporations, military assignments, or government agencies.

A. CURRENT AFFILIATIONS (Attach additional sheets if necessary. Reference this section number and title.)

 

 

Name and Mailing Address of Primary Admitting Hospital:

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Department/Status (Active, provisional, courtesy, etc.):

 

Appointment Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and Mailing Address of Other Hospital/Institution:

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Department/Status (Active, provisional, courtesy, etc.):

 

Appointment Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and Mailing Address of Other Hospital/Institution:

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Department/Status (Active, provisional, courtesy, etc)

 

Appointment Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you do not have hospital privileges, please explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. PREVIOUS AFFILIATIONS (Limit to last ten years. Attach additional sheets if necessary. Reference this section number and title.)

 

Name and Mailing Address of Other Hospital/Institution:

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From: (mm/yy)

 

 

To: (mm/yy)

 

Reason for Leaving:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and Mailing Address of Other Hospital/Institution:

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From: (mm/yy)

 

 

To: (mm/yy)

 

Reason for Leaving:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and Mailing Address of other Hospital/institution:

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From: (mm/yy)

 

 

To: (mm/yy)

 

Reason for Leaving:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mississippi Participating Physician Application – 11/99

 

 

 

 

 

 

 

 

 

Page 7 of 12

Name and Mailing Address of Other Hospital/Institution:

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From: (mm/yy)

To: (mm/yy)

Reason for Leaving:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XIX. PEER REFERENCES

List three professional references, preferably from your specialty area. Do not list relatives, current partners or associates in practice. If possible, include at least one member from the Medical Staff of each facility at which you have privileges. Do not include program directors previously listed under post graduate training and education in Section X.

NOTE: References must be from individuals who are directly familiar with your work, either via direct clinical observation or through a close working relationship.

Name of Reference:

Specialty:

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Reference:

 

Specialty:

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Reference:

 

Specialty:

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XX. WORK HISTORY (Attach additional sheets if necessary. Reference this section number and title.)

Chronologically list all work history for at least the past five years (use extra sheets if necessary). This information must be complete. A curriculum vitae is sufficient provided it is current and contains all information requested below. Please explain any gaps in professional work history on a separate page.

 

Current Practice:

 

Contact Name:

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From: (mm/yy)

 

 

 

 

 

 

To: (mm/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Practice/Employer:

 

Contact Name:

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From: (mm/yy)

 

 

 

 

To: (mm/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mississippi Participating Physician Application – 11/99

 

 

 

 

 

 

 

 

 

Page 8 of 12

 

Name of Practice/Employer:

 

Contact Name:

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

ZIP:

From: (mm/yy)

To: (mm/yy)

Section B.

Professional Liability Action Explanation

Please complete this section for each pending, settled, or otherwise concluded professional liability lawsuit or arbitration filed and served against you, in which you were named a party in the past five (5) years, whether the lawsuit or arbitration is pending, settled or otherwise concluded, and whether or not any payment was made on your behalf by any insurer, company, hospital, or other entity. All questions must be answered completely in order to avoid delay in expediting your application. If there is more than one professional liability lawsuit or arbitration action, please photocopy this Section B prior to completing, and complete a separate form for each lawsuit.

I. CASE INFORMATION

City, County and State where lawsuit filed:

Court case number, if known:

Date of alleged incident serving as basis for the lawsuit/arbitration:

Date Suit Filed:

Sex of patient:

Age of patient:

 

Location of Incident:

 

 

 

 

 

 

 

 

Hospital

My office

Other doctor’s office

Surgery Center

 

Other, (please specify)

__________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

Your relationship to Patient (Attending Physician, Surgeon, Assistant, Consulting, etc.):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Allegation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is/was there any insurance company or other liability protection company or organization providing coverage/defense of the lawsuit or

arbitration action?

Yes

No

If Yes, please provide company name, contact person, phone number, location and claim identification number of insurance company or other liability protection company or organization.

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

If you would like us to contact your attorney regarding any of the above, please provide attorney(s) name(s) and phone number(s). Please fax this document to your attorney to serve as your authorization:

Name: ____________________________________________________ Phone Number: _________________________________

Name: ____________________________________________________ Phone Number: __________________________________

II. WHAT IS THE STATUS OF THE LAWSUIT/ARBITRATION DESCRIBED ABOVE? (CIRCLE ONE)

Lawsuit/arbitration still ongoing, unresolved.

 

 

 

 

Judgement rendered and payment was made on my behalf.

Amount paid on my behalf:

_______________________

Judgement rendered and I was found not liable.

 

 

 

 

Lawsuit/arbitration settled and payment made on my behalf.

Amount paid on my behalf:

________________________

Lawsuit/arbitration settled, no judgement rendered, no payment made on my behalf.

Summarize the circumstances giving rise to the action. If the action involves patient care, provide a narrative, with adequate clinical detail, including your description of your care and treatment of the patient. If more space is needed, attach additional sheet(s). Include: (1) condition and diagnosis at time of incident. (2) dates and description of treatment rendered, and (3) condition of patient subsequent to treatment. Please print.

Mississippi Participating Physician Application – 11/99

Page 9 of 12

SUMMARY

SECTION C.

Certification

I certify that the information in Section A and B of this application and any attached documents (including my curriculum-vitae if attached) is true, current, correct and complete to the best of my knowledge and belief and is furnished in good faith. I understand that intentionally withholding or omitting material information or intentionally submitting material false or misleading information may result in denial of my application or termination of my privileges, employment or physician participation agreement. I agree that the Managed Care Entity to which this application is submitted, its representatives, and any individuals or entities providing information to this Managed Care Entity in good faith shall not be liable, to the fullest extent provided by law, for any act or occasion related to the evaluation or verification contained in this Mississippi Participating Physician Application. In order for participating Managed Care Entities or Healthcare Organizations to evaluate my application for participation in and/or my continued participation in those organizations, I hereby give permission to release to this Managed Care Entity information about my medical malpractice insurance coverage and malpractice claims history. This authorization is expressly contingent upon my understanding that the information provided will be maintained in a confidential manner and will be shared only in the context of legitimate credentialing and peer review activities. This authorization is valid unless and until it is revoked by me in writing. I authorize the attorneys listed in Section B, Page 9, to discuss any information regarding the subject case with this Managed Care Entity.

Print Name Here: ___________________________________________________________________________

Physician Signature: ____________________________________________________________ Date: __________________________

(Stamped Signature Is not Acceptable)

Mississippi Participating Physician Application – 11/99

Page 10 of 12
⇓ Mississippi Participating Application

Document Features

# Fact Name Description Governing Law(s)
1 Application Purpose The form is used for both original applications and reappointments for physicians wishing to participate in a Managed Care Entity in Mississippi. N/A
2 Confidentiality Notice The form starts with a CONFIDENTIAL/PROPRIETARY notice, indicating the sensitive nature of the information provided. N/A
3 Required Information Types Applicants must provide practice, educational, licensure, and work history information. N/A
4 Submission Instructions Instructions state the form must be typed or printed in black ink and additional sheets can be attached if more space is needed. N/A
5 Required Documents Applicants must submit current copies of their state medical license(s), DEA certificate, and other relevant documents. N/A
6 Accessibility Options The form asks whether the office is accessible to persons with disabilities and if there is 24-hour coverage available. N/A
7 Practice Information It includes detailed sections on practice information, including whether the applying physician will accept new patients. N/A
8 Medical Education and Board Certifications The applicant must detail their educational background, residencies/fellowships, and any board certifications. N/A
9 Licensure Verification Details of medical licensure, DEA registration, and any controlled dangerous substances certification must be provided. N/A
10 Office Hours and Coverage Applicants are required to specify their office hours including coverage on weekends and holidays. N/A

Mississippi Participating Application - Usage Instruction

Filling out the Mississippi Participating Application form is a critical step for physicians aiming to affiliate with a Managed Care Entity in Mississippi. This application is both a testament to the physician's qualifications and a blueprint of their practice details. Following the instructions meticulously ensures that the application accurately reflects the physician’s credentials and capabilities. Below are step-by-step instructions to guide physicians through the application process.

  1. Begin by choosing the application type: "Mississippi Participating Physician Original Application" or "Application Reappointment", and submit it to the Managed Care Entity specified on the form.
  2. Section A: Fill in Practice, Educational, Licensure, and Work History Information. Use black ink and attach additional sheets if needed, clearly indicating the questions being answered.
  3. Under the instructions section, verify that all necessary documents are current and attached, including State Medical License(s), Professional Liability Policy, DEA Certificate, Curriculum Vitae, Board Certification, and ECFMG certificate if applicable.
  4. In the Identifying Information section, provide your legal name, any aliases, contact information, birth details, citizenship status, and professional details like specialty and subspecialties.
  5. Detail your Practice Information accurately, including office addresses, tax identification numbers, and any affiliations with medical groups or networks. Indicate if you accept new patients and have ownership in health-related businesses.
  6. Indicate if you employ allied health professionals or other physicians, including their names and license numbers.
  7. Describe any clinical services and limitations pertinent to your specialty, your practice's EDI capabilities, and the type of anesthesia you provide.
  8. If applicable, list any accreditations, certifications, or licenses your practice has received.
  9. In the Billing Information section, provide details about your billing company, its address, and your tax ID number.
  10. Detail your Office Hours and Coverage, including your answering service and covering physicians.
  11. Note any Foreign Languages spoken fluently by you or your staff.
  12. If providing Laboratory Services, indicate your Tax ID number, if you have a CLIA Certificate or waiver, along with its details.
  13. Document your Medical/Professional Education, Internships, Residences/Fellowships thoroughly. If additional space is needed, attach extra sheets referencing this section.
  14. Complete the Board Certification and Other Certifications sections by listing all applicable credentials and attaching copies of documents.
  15. For the Medical Licensure/Registrations, provide your Mississippi State Medical License Number, DEA Registration Number, and Controlled Dangerous Substances Certificate if applicable, along with expiration dates and other pertinent information.

After carefully completing all sections, review your application for accuracy and completeness. Ensuring all details are correctly entered and all required documents are attached is paramount in avoiding delays in the processing of your application. Submit the completed form to the identified Managed Care Entity, poised for the next steps towards your participating physician status in Mississippi.

Common Questions

What documents are needed to submit with the Mississippi Participating Physician Application?

When submitting your Mississippi Participating Physician Application, you need to include current copies of the following documents: State Medical License(s), Face Sheet of Professional Liability Policy or Certification, DEA Certificate, Curriculum Vitae, Board Certification (if applicable), and ECFMG (if applicable).

How should the application be completed?

The application must be typed or legibly printed in black ink. Avoid abbreviations and attach additional sheets as necessary, referencing the questions being answered. If a question does not apply to you, write N/A in the provided box.

Is information about race, ethnicity, and gender necessary on the application?

Yes, information regarding race, ethnicity, and gender is required. This information will be used solely for consumer information purposes.

What should I do if I have more practice locations than the space provided on the form?

If you have more practice locations than the space provided, attach additional sheets to the application. Make sure to reference the specific questions your additional information relates to.

Can I submit my application if I am not a United States citizen?

Yes, non-U.S. citizens can submit the application. However, they must include a copy of their Alien Registration Card with the application.

What is required regarding hospital privileges and continuity of care?

If you do not have hospital privileges, you are required to provide a written plan for continuity of care for your patients.

How should board certifications and medical licenses be handled in the application?

Include copies of your board certifications and medical licenses with the application. If applying for or intend to apply for board certification, provide details separately, including your plans and the date of admissibility for certification. Clearly disclose any board exam failures, providing details as requested.

Common mistakes

  1. Failing to type or legibly print in black ink can lead to misinterpretation of the information provided. This application form requires clarity to ensure accuracies in processing.

  2. Using abbreviations instead of complete words, despite the instructions explicitly stating to avoid them. Abbreviations can lead to confusion or incorrect interpretation of critical information.

  3. Not attaching additional sheets when more space is needed, or improperly referencing these extended answers to the corresponding questions in the original form. This mistake can result in incomplete information being reviewed.

  4. Omitting required documents such as a current state medical license, DEA certificate, or proof of board certification (if applicable). These documents are essential for verifying credentials and qualifications.

  5. Incorrectly filling out the section regarding professional liability policy information, perhaps by not providing a face sheet or certification. This error could impact the application's consideration for approval.

  6. Leaving blank spaces or entering "N/A" improperly when certain items do not apply. Accurate and complete responses, even those indicating non-applicability, are crucial for thorough review.

  7. In the practice information section, failing to accurately detail secondary or tertiary office locations, including the associated tax ID numbers and office manager/administrator contact information, can cause delays or issues in the application process.

  8. Not specifying any limitations in practice, such as ages treated or types of services performed/not performed, which is important information for managed care entities to understand the scope of practice.

  9. Incorrectly filling out the coverage of practice section or not providing a complete plan for continuity of care if hospital privileges are not held. This information is crucial for managed care entities to ensure patient care standards are met.

Common pitfalls in completing the Mississippi Participating Physician Application form range from administrative oversights to omissions of critical documentation. Each section of the form is designed to gather comprehensive information about the applicant's qualifications, scope of practice, and operational protocols. Thoroughly and accurately completing the form is essential for a successful application process.

Documents used along the form

When submitting a Mississippi Participating Physician Application, healthcare providers are often required to provide additional documentation to complete their application process fully. These documents play a crucial role in demonstrating the qualifications, background, and legal compliance of the applicants. To ensure a smooth and successful application process, understanding these complementary documents is essential.

  • Curriculum Vitae (CV): A comprehensive record highlighting an applicant's education, publications, job history, and professional achievements.
  • State Medical License(s): Proof of the applicant's authorization to practice medicine in Mississippi or other states.
  • Professional Liability Insurance Certificate: Evidence of current malpractice insurance coverage, showing the applicant's policy details.
  • DEA Certificate: A document confirming the applicant's registration with the Drug Enforcement Administration, authorizing them to prescribe controlled substances.
  • Board Certification: Certificates demonstrating the applicant has met the specialty qualifications beyond the basic medical license, if applicable.
  • ECFMG Certificate: For international medical graduates, this certifies they have met the education, training, and examination requirements to practice in the U.S.
  • CLIA Certificate: For offices that perform laboratory testing, this certification ensures compliance with quality standards.
  • Proof of Continuing Medical Education (CME): Documentation showing ongoing educational activities to maintain competence and learn about new and developing areas of their field.
  • Medicare/Medicaid Enrollment Documentation: For providers participating in Medicare or Medicaid, proof of enrollment is necessary.
  • Alien Registration Card (Green Card): For non-U.S. citizens, evidence of legal permission to work in the United States.

These documents supplement the information provided in the Mississippi Participating Physician Application, offering a comprehensive profile of the applicant's professional and legal standings. Collecting and presenting these documents meticulously is key to demonstrating eligibility and readiness to provide high-quality healthcare services under the managed care entity. Ensuring accuracy and completeness of this documentation facilitates the evaluation process, helping to establish the trust and reliability essential in healthcare partnerships.

Similar forms

The Mississippi Participating Physician Original Application is akin to a Medical Staff Credentialing Application common in many healthcare institutions. This type of form is used by hospitals and health systems to gather the necessary information to verify the qualifications, experience, and training of physicians seeking privileges to practice within the institution. Both forms require detailed professional history, including education, residencies, fellowships, and board certifications, ensuring the physician meets the high standards necessary for patient care within their facilities.

Similar to the Employment Application Form for healthcare positions, the Mississippi Participating Application collects comprehensive personal and professional data. Both documents serve as an initial step in the employment or credentialing process, featuring sections on work history, educational background, licenses, and certifications. The key difference lies in their specific focus areas, with employment applications often broader in scope and the Mississippi form tailored towards participating physicians within managed care entities.

A Provider Enrollment Form, used by healthcare providers to enroll in health plans or networks, shares similarities with the Mississippi Participating Application. Both require detailed information about the provider, including licensure, certification, and practice information. The goal is to streamline the process by which providers join a network or health plan, ensuring they meet the necessary criteria for participation and billing purposes.

The Physician Credentialing Application, another document with a similar purpose, also aims to verify a physician's qualifications and background for the purpose of joining a hospital staff or health network. It typically includes detailed queries about medical education, training, board certification, and professional history, much like the Mississippi Participating Application. Both forms entail a rigorous vetting process to uphold healthcare standards.

The Health Insurance Portability and Accountability Act (HIPAA) Business Associate Agreement parallels the Mississippi application in its emphasis on confidentiality and privacy. Although the Business Associate Agreement specifically addresses the handling of protected health information (PHI) between covered entities and their business associates, the confidentiality notice in the Mississippi form underscores a commitment to maintaining the privacy of the information provided by the physicians.

The Clinician’s DEA Registration Form shares commonalities with the Mississippi form through its inclusion of DEA certification information. The DEA form is specifically for registrants authorized to prescribe, distribute, and administer controlled substances, highlighting the necessity for physicians in the Mississippi application to provide their DEA registration numbers, reflecting their legal ability to handle controlled substances within their practice.

The National Provider Identifier (NPI) Application Form, required for all healthcare providers under HIPAA, is akin to the Mississippi Participating Application in that both require specific identifiers for healthcare providers. While the NPI form focuses solely on obtaining a unique identifier for billing and identification across healthcare systems, the Mississippi application uses such identifiers as part of a broader set of credentials necessary for participation within a managed care network.

The Continuing Medical Education (CME) Reporting Form, although distinct in its purpose to track ongoing education and training, relates to the educational and certification sections of the Mississippi Participating Application. Both emphasize the importance of continuous learning and submission of relevant documentation to maintain credentials and ensure up-to-date practice methodologies.

The Professional Liability Insurance Application, similarly, demands detailed information about a physician's insurance coverage, mirroring sections in the Mississippi application that require submission of current professional liability insurance documents. This ensures that participating physicians within the managed care entity have adequate coverage, reflecting a shared concern for mitigating risks and protecting patient welfare.

The Clinical Privileges Application, required for physicians seeking specific procedural privileges within a healthcare facility, resembles the Mississippi Participating Application in its thorough vetting of a physician's qualifications and experience specific to certain clinical services. Both documents play crucial roles in ensuring that physicians are adequately qualified for the services they intend to offer, safeguarding patient safety and care quality.

Dos and Don'ts

When completing the Mississippi Participating Application form, there are critical steps to follow to ensure the process is smooth and the application is submitted accurately. Below are lists of things you should do and things you should avoid.

Do the following:

  1. Fully read the instructions at the beginning of the form to understand the requirements and how to complete the form correctly.
  2. Type or legibly print in black ink to ensure all information is readable and clear, minimizing the risk of mistakes or misinterpretations.
  3. Provide accurate and up-to-date documents such as your State Medical License(s), DEA Certificate, and Curriculum Vitae as requested in the application.
  4. Complete every section thoroughly, and for sections that do not apply to you, mark them as N/A to indicate that you have reviewed the section and found it not applicable.
  5. Include additional sheets for information that does not fit in the provided space, and clearly reference the question you are answering on these sheets.
  6. Verify all personal and professional information for accuracy before submission to avoid delays in processing your application.

Avoid the following:

  1. Do not use abbreviations as instructed, since not everyone may be familiar with them, leading to confusion or misinterpretation.
  2. Avoid leaving any sections blank without indicating N/A where applicable, as missing information could delay the processing of your application.
  3. Do not submit outdated or incorrect documents; always double-check that everything is current and accurate.
  4. Avoid rushing through the form; take the time to ensure every detail is complete and correct.
  5. Do not ignore the need for additional sheets if more space is needed. Failing to provide complete answers can result in an incomplete application.
  6. Finally, avoid submitting the form without a final review. Check for errors, completeness, and ensure that all required documents are attached.

Misconceptions

Many professionals find the process of applying for participation in a Mississippi Managed Care network daunting due to misunderstandings and misconceptions about the application form. Here are five common misconceptions cleared up to make the process less intimidating:

  • Every section applies to every applicant: It may seem like you need to fill out each section comprehensively. However, if certain sections don't apply to you, it's perfectly acceptable to mark these as 'N/A'. This approach is specifically mentioned in the instructions, ensuring that the form remains relevant to your particular circumstances.
  • Abbreviations are acceptable: Despite what some might think, the instructions explicitly state that abbreviations should not be used when completing the application. The reason behind this directive is to ensure clarity and prevent any potential misunderstandings regarding the information provided.
  • Electronic submissions are preferred: The form clearly specifies that it should be typed or legibly printed in black ink, which suggests a preference towards physical submission. This detail is crucial for applicants to recognize, as it may affect the format in which they prepare and send their application to the Managed Care Entity.
  • Professional liability information is optional: A common misconception is that details relating to professional liability, such as the face sheet of the Professional Liability Policy or Certification, are optional. In reality, current copies of these documents must be submitted with the application. This requirement underscores the importance of transparency in professional practices and ensures that all participating physicians meet a standard level of accountability.
  • Gender and ethnicity information is used for discriminatory purposes: This incorrect belief misses the fact that such personal information is solely intended for consumer information purposes. The application specifically addresses this concern, indicating a commitment to using this data responsibly and ethically.

Understanding these nuances can greatly simplify the process of completing the Mississippi Participating Application form. The key is to read the instructions thoroughly, adhere strictly to the specifications provided, and approach the application with clarity and honesty. This way, physicians can navigate the process smoothly, contributing to an efficient and effective healthcare system.

Key takeaways

Completing the Mississippi Participating Application form is a critical step for physicians in Mississippi to become part of a managed care entity. Here are five key takeaways to ensure the process is completed efficiently and accurately:

  • The application must be filled out clearly and legibly, using black ink or typed text. This ensures that all information is easily readable and reduces the risk of errors or delays in processing.
  • Applicants are advised not to use abbreviations and to attach additional sheets if the space provided on the form is insufficient. This approach helps in providing detailed and complete responses to all questions.
  • Current copies of essential documents including State Medical License(s), DEA Certificate, Professional Liability Policy or Certification, Curriculum Vitae, and Board Certification (if applicable) must accompany the application. These documents are crucial for verifying the qualifications and professional standing of the applicant.
  • If any item on the application does not apply, writing "N/A" in the provided box is necessary. This indicates that the question has been read but is not applicable to the applicant’s situation, ensuring that no sections are mistakenly skipped.
  • All applications are treated as confidential and proprietary, signifying that the information provided will be handled with the utmost discretion and according to privacy laws and regulations.

It’s important for applicants to thoroughly review and double-check all sections of the application to avoid common mistakes or omissions. Attention to detail can significantly streamline the verification process and increase the chances of a successful application with the desired managed care entity.

Please rate Download Mississippi Participating Application Form Form
4.73
First-rate
179 Votes

Popular PDF Forms

How to Create a Job Application - Applicants are encouraged to carefully read all instructions and ensure all sections of the form are completed to prevent processing delays.

0978 Mississippi - Designed for easy remittance, the form specifies where to send payments and how to designate checks for processing.

Mississippi Accident Reports - Designed for use by law enforcement to document vehicular accidents comprehensively for investigative purposes.