KAISER PERMANENTE Provider Application for Participation Instructions
- June 8, 2024
- KAISER PERMANENTE
Table of Contents
KAISER PERMANENTE Provider Application for Participation
INSTRUCTIONS
This is a PRACTITIONER APPLICATION for consideration into Kaiser Permanente’s
network of providers.
This application is only for providers, such as physicians, behavioral health
practitioners, physical, occupational and speech therapists and other
professionals. For consideration for inclusion into our network of providers,
please complete this application in its entirety and submit it as indicated
below. This application should not be used by existing network providers to
make demographic changes or add providers to your practice.
Important disclaimer: All Information provided will be assessed against Kaiser Permanente’s network needs. Submission of an application does not constitute any obligation on the part of Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., the Mid-Atlantic Permanente Medical Group, P.C. or any other or related Kaiser Permanente entity to enter into a contractual obligation.
It is important that you clearly describe the services you offer so that we can best assess our need for your offered services. Your completed application must also include the attached Disclosure of Ownership and Control Information form. Additional pages are provided to list additional providers.
Please complete this application electronically. Do not complete it by hand.
We welcome any attachments, brochures or descriptions you may choose to
include to support your application.
Incomplete applications will be automatically denied and returned to you at
the contact address within ten (10) days of receipt. We will process complete
applications and provide notice of our decision in writing within thirty (30)
days.
- For questions, please contact us at [email protected].
- Return completed applications using one of the following options:
Email PDFs to: [email protected]
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. Mid-Atlantic Permanente Medical Group, P.C.
Do you maintain general liability insurance of at least $1,000,000/$3,000,000? Do you agree to facilitate all necessary credentialing activities?
EPSDT (Maryland Healthy Kids/ Early Periodic Screening, Diagnosis and Treatment Program). Visit http://dhmh.maryland.gov/epsdt/.
EPSDT (Maryland Healthy Kids/ Early Periodic Screening, Diagnosis and Treatment Program). Visit http://dhmh.maryland.gov/epsdt/.
EPSDT (Maryland Healthy Kids/ Early Periodic Screening, Diagnosis and Treatment Program). Visit http://dhmh.maryland.gov/epsdt/.
EPSDT (Maryland Healthy Kids/ Early Periodic Screening, Diagnosis and Treatment Program). Visit http://dhmh.maryland.gov/epsdt/.
EPSDT (Maryland Healthy Kids/ Early Periodic Screening, Diagnosis and Treatment Program). Visit http://dhmh.maryland.gov/epsdt/.
This section must be completed by an authorized representative of the participating provider practitioner, group or facility. An authorized representative is defined as an individual with designated authority to act on behalf of the individual, group of practitioners or disclosing entity. If not a solo practitioner, then the authorized representative must be a partner, president or secretary of the group of practitioners.
-
Ownership and Control Information for Disclosing Entity, 42 C.F.R. §455.104
List any individual who has any ownership or controlling interest in this provider entity or in any subcontractor. List the name, title, (e.g., CEO, President), address, Tax ID Number of any organization, corporation or entity having any ownership or controlling interest in this provider entity. The ownership or controlling interest is an ownership interest of 5% or more in this provider entity. -
Relationships
List any individuals named in Question 1 whom are related to each other (e.g., spouse, parent, child or sibling). List their name, state their relationship and include their Social Security Number. -
Subcontractor
List any individual with an ownership or control interest in any subcontractor that the disclosing entity has direct or indirect ownership of 5% or more. -
Other Disclosing Entity
List the name, address and Tax ID Number of any other disclosing entity other than a subcontractor in which a person with an ownership or controlling interest in this disclosing entity has an ownership or control interest of 5% or more. -
Criminal Offenses
Has any individual or organization listed in Questions 1, 2, 3 and 4 ever been convicted or assessed fines or penalties for any health-related crimes or misconduct and/or excluded from any federal or state health care program due to fraud, obstruction of an investigation, a controlled substance violation or any other crime or misconduct? If your answer to this question is YES, please provide the name, address, Social Security Number, Tax ID Number and percentage of ownership for these individual(s) and/or organization(s).Yes No -
Criminal Offenses
Has ANY individual or contractor connected with your practice been convicted or assessed fines or penalties for any health-related crimes or misconduct, or excluded from any federal or state health care program due to fraud, obstruction of an investigation, a controlled substance violation or any other crime or misconduct? If your answer to this question is YES please provide the name, address, and Social Security Number/Tax ID Number for individual(s) or contractor(s).Yes No -
Criminal Offenses
Has the applicant ever had any adverse legal actions imposed by Medicare, Medicaid or any other federal or state agency or program, or any licensing or certification agency?Yes No
If yes, please provide a copy of relevant final disposition.
References
- Maryland.gov - Official Website of the State of Maryland
- CAQH - Streamlining the Business of Healthcare