Provider Name:
TIN:
Practice Name:
Provider Joining Practice
Provider Leaving Practice
Terminate Location
Other:
Site Address:
Effective Date:
Add Location
Type of service provided:
Change Billing Address
primary care specialist
non-primary care specialist
**COMPLETE REMAINING INFORMATION FOR ADDING OR JOINING PRACTICE ONLY**
List the names of colleagues providing regular coverage, their specialties and coverage arrangements:
List names of partners in your practice:
After hours, back office phone number for health plan business use only:
Office business hours, hours that patients are seen:
Evening or weekend hours:
Do you want to list site in the directory?
Do you make 24-hour/7 day a week phone coverage available?
If Yes, Indicate type of coverage arrangements.
Yes
No
Yes
No
BILLING INFORMATION:
BILLING ADDRESS:
E-mail for billing contact:
Department name if hospital based:
Who check should be payable to:
Billing representative’s name:
Do you accept new patients into your practice?
Accept new patients from physician referral
Yes
No
Yes
No
(specify for each health plan)
only?
Accept all new patients?
Accept new Medicare patients?
Yes
No
Yes
No
Accept existing patients with change of payor?
Accept new Medicaid patients?
Yes
No
Yes
No
Practice limitations: (patient ages, sex)
Do nurse practitioners, physician assistants, midwives, social workers,
If yes, provide name, address, state license, specialty, if contracted as a
or other non-physician providers provide care to patients in your
PCP.
practice?
Yes
No
Availability of interpreters (specify languages):
Do you provide handicap accessibility for each of the following areas:
Building
Yes
No
Parking
Yes
No
Restroom
Yes
No
If yes, indicate types of transportation. Taxi
Is the site accessible by public transportation?
Yes
No
Does your site provide childcare services? (for each site)
Yes
No
Does your site have other services for the disabled (Test Telephony – TTY, American Sign Language
Yes
No
– ASL, or other)?
Does your office qualify as a minority business enterprise?
Yes
No
Do you or someone in your office have the following additional certifications? (show expiration dates.)
BLS (Basic Life Support)
Expiration date:
Yes
No
ACLS (Advanced Cardiac Life Support)
Expiration date:
Yes
No
ALSO (Advance Life Support in OB)
Expiration date:
Yes
No
PALS (Pediatric Advanced Life Support) Classification
Expiration date:
Yes
No
ATLS (Advanced Trauma Life Support) Certified
Expiration date:
Yes
No
NALS (Neonatal Advanced Life Support)
Expiration date:
Yes
No
NRS (Neonatal Resuscitation Program) Classification
Expiration date:
Yes
No
CPR classification
Expiration date:
Yes
No
Additional office services provided:
Laboratory services provided
Flexible sigmoidoscopy
Yes
No
Yes
No
Radiology Service
Tympanometry/audiometry screening
Yes
No
Yes
No
EKGs
Asthma treatment
Yes
No
Yes
No
Care of minor lacerations
Osteopathic manipulation
Yes
No
Yes
No
Pulmonary function
IV hydration/treatment
Yes
No
Yes
No
Allergy injections, allergy skin testing
Cardiac stress tests
Yes
No
Yes
No
Office gynecology (routine pelvic/pap)
Physical therapy
Yes
No
Yes
No
Drawing blood
Additional office procedures provided
Yes
No
Yes
No
Age appropriate immunizations
Yes
No
Surgical procedures
Is anesthesia administered in your office?
Yes
No
If yes, what category of anesthesia do you use?
Specify the class or category:
Who administers it?
Additional Comments:
Yes
No
Practice Name:
Provider Joining Practice
Provider Name:
TIN:
Provider Leaving Practice
Terminate Location
Other:
Effective Date:
Add Location
Change Billing Address
CONTRACT PARTICIPATION
Please update all contracts that this provider is associated with through Central Georgia Medical Care Network
Please only update the following contracts for this provider through Central Georgia Medical Care Network:
Date Applied
Date Approved
Commercial
Aetna (HMO, POS, and PPO)
Beechstreet (PPO, Wk Comp)
Cigna (GPPO, PPO, Great West)
Coventry (HMO, PPO, Wk Comp, First Health, Mail Handlers, Focus,
GEHA)
Corvel (PPO, Wk Comp)
Evolutions (Wk Comp)
Galaxy
Humana Choicecare HMO
Humana Choicecare PPO
IBG (Industry Buying Group)
Perdue Farms
PHCS/MultiPlan (PPO)
Starcare
United Healthcare (All Products)
Worker’s Comp
Choice Med Mgmt./Genex
Heritage Summit (Synergy)
Medicare Advantage
Humana Medicare Advantage PPO
Care Improvement Plus
Medicaid
Amerigroup
Peachstate
Wellcare
We can assist you with the application process for the following individually contracted plans:
*Please complete applicable applications
*Blue Cross Blue Shield (HMO, PPO, Par)
*Tricare (Standard, Prime)
*Secure Heath (Patient Select)
*CGHN (PHO Macon)
Signature: _____________________________________________ Date:___________