New Provider Application

27 years of credentialing with Berkeley Associates

Attention Providers

Please complete the information in full and submit when complete. If you have questions or need to gather information, you are able to save and return to complete it at a later time.

You can do so by clicking the “Save & Continue” button. You will be emailed a secure link that will bring you back to where you are in the process.

New Provider Application

Step 1 of 11

Comments

This field is for validation purposes and should be left unchanged.

Provider Type(Required)

APRN / PA

MD / DO / OD

PT / OT / ST

AUD

Behavioral Health

Legal name(Required)

First Last

Title

Other

Title

APRN

Other

Title

LPC

MSW

PhD

Other

Personal Information

Have you ever gone by any other name?

Yes

LIST prior names below with dates:

Have you ever served in the Military?

Yes

If yes, are you currently on active military duty?

Yes

Are you a citizen of the United States?

Yes

If no, country of citizenship:

Please upload a copy of VISA:

Max. file size: 512 MB.

Date of Birth:

MM slash DD slash YYYY

Place of Birth

(City, State/Province, Country)

SSN:

Upload Driver's License or State Issued ID:

Max. file size: 512 MB.

List any languages you speak other than English:

Upload Resume or CV:

Max. file size: 512 MB.

Personal Cell Phone(Required)

Your Email Address(Required)

Enter Email Confirm Email

Preferred method of communication for this application:

Text

Cell phone

Home Address:

Street Address City State / Province / Region ZIP / Postal Code

Practice Information

Type of provider

PCP

Specialist

Hospitalist

Urgent Care

Please select all that apply.

Name of Group

Website

Primary Specialty:

Secondary Specialty:

Gender Limitations:

None

Male Only

Female Only

Other

Practitioner Location Type(Required)

Office

Clinic

ASC

Hospital

Home

Practitioner Location Type(Required)

Office

Clinic

Home

Operating hours and weekdays:

Do you intend to practice at more than one location with this group?

Yes

List location individually:

Click the plus at right for additional locations.

Location City/Region

Street Address & ZIP

Practitioner Primary Hospital Affiliation

Admitting Privileges

Yes

I don't know

Practitioner Secondary Hospital Affiliation

Admitting Privileges

Yes

I don't know

Behavioral Health Information

CLINICAL EXPERTISE (SPECIALTIES):

From the list below, select a maximum of six (6) specialty areas for which you have training and expertise. If you indicate more than six specialties, they will not be documented. These specialties will be used to assist Beacon Health Options in making clinically appropriate referrals. Please remember to select applicable specialties when applying for the specialty networks.

Addictions, Non-Chemical (S.ANC)

Adoption (S.ADP)

Affective Disorders (S.AFF)

Alcohol/ChemicalDependency(S.ACD)

Anger Management/Impulse Disorders (S.ANG)

Anxiety Disorders (S.ANX)

Applied Behavioral Analyst

Autism Spectrum Disorders (S.ASP)

Attention Deficit Hyperactivity Disorder (ADHD)

School-related problems (S.ADD)

Childhood Behavioral Disturbances(S.CBD)

Chronic Pain (S.CHP)

Co-Occurring Disorders (S.COD)

Death & Dying/Terminal Illness (S.CHT)

Disability Assessment (M.DSA)

Disability Treatment (S.DST)

Dissociative Identity Disorders (S.MPD)

Domestic Violence (S.VIO)

Gangs/Cults (S.GNG)

EatingDisorders(S.EAT)

Fitness for Duty Assessment M.FDE)

Forensics (S.FOR)

Gay/Lesbian/Bisexual/Transgender/Sexual (S.GLS)

Geropsychiatry/Alzheimers (S.GAL)

Grief/Bereavement (S.GRF)

Head Trauma (S.HTR)

Hearing Impaired (S.HIM)

HIV/AIDS (S.HIV)

Marital/Separation/Divorce (S.MAR)

Men's Issues (120C) S.MEN)

Mental Retardation/ Developmental Disabilities (S.MRI)

Military Lifestyle Issues (S.MIL)

Neuropsychology (S.NEU)

Obsessive Compulsive Disorder (S.OCD)

Panic/Phobias (S.PHO)

Personality Disorders (S.PER)

PhysicalAbusePerpetrators(S.PAP)

Physical Abuse Victims (S.PAV)

Post-Traumatic Stress Disorder (S.PSD)

Reactive Attachment Disorder (S.RAP)

Schizophrenia (S.SCH)

Severe & Persistent Mental lllness(S.SPM)

Sex Abuse Perpetrators (S.SAB)

Sex Abuse Victims (S.SAB)

Sexual Dysfunction (S.DYF)

Sleep Disorders (S.SLP)

Suboxone Therapy (S.SUB)

Trichotillomania (S.TRM)

Women's Issues (S.WMN)

Telehealth Services (S.THS)

THERAPEUTIC MODALITIES:

From the list below, please select a maximum of six (&) modality areas that you use when treating patients. These modalities will be used to assist Beacon Health Options in making clinically appropriate referrals. Please remember to select applicable modalities when applying for the specialty networks.

Behavior Modification Therapy (M.BEH)

Brief Therapy (M.BRF)

Child Therapy (M.CHI)

Child Therapy (Sy and younger) (M.CHY)

Cognitive Behavioral Therapy (M.COG)

Critical Incident Stress Management

Dialectical Behavioral Therapy (M.DBT)

DFWP (Drug Free Workplace; Federally Required training & consultations); EAP/ Organizational Development/ Workplace Issues; Stress Management (M.WRK)

ECT Inpatient (M.ECT)

ECT Outpatient (M.ECO)

Family Therapy (M.FAM)

Neuropsychological Testing (M.NSY)

Pastoral Counseling (M.CHR)

Play Therapy (M.PLY)

Psych Testing (M.PST)

Psychopharmacology (M.PSP)

Solution Focused Therapy (M.SFT)

Worker's Comp Evaluations (M.WCE)

PT / OT / ST Information

Will you be providing services in a clinic that you own?

Yes

Will you be leasing space from another provider?

Yes

Do you have an agreement on designated space while you are providing services?

Yes

Please provide a copy of your agreement:

Max. file size: 512 MB.

Covering Physician

Physician's Full Name

Covering Physician's Specialty

Covering Physician's Phone

Credentials

CAQH Credentialing:

If you do not have this, we will set up a CAQH data file it. (See notes)

CAQH number:

**CAQH Username:

CAQH Password:

**NPI Username

(See notes)

NPI Password

Individual Medicare number:

Individual Medicaid number:

Do you have Medicaid outside of Oklahoma?(Required)

Yes

If you do not have a CAQH number, we will set that up for you. We can also assist with your login and password if you do not have access to that.

Individual NPI – We will contact you and assist with this if you do not have your NPI information.

Individual Medicaid number - We are able to get this information if it is not available to you.

Board Certification Number:

Certification Date:

Upload Copy of Certificate:

Max. file size: 512 MB.

State License Number:

Licensing State:

Upload License:

Max. file size: 512 MB.

2nd State License Number:

2nd Licensing State:

Upload 2nd License:

Max. file size: 512 MB.

3rd State License Number:

3rd Licensing State:

Upload 3rd License:

Max. file size: 512 MB.

Scripts

Do you have a Current DEA?

Yes

Do you have a current BNDD?

Yes

Upload DEA:

Max. file size: 512 MB.

Upload BNDD:

Max. file size: 512 MB.

If not, who will write scripts?

Insurance

Do you have current liability insurance?(Required)

Yes

Upload copy of current liability insurance:

Max. file size: 32 MB.

Have you had previous carriers in the last 10 Years?(Required)

Yes

If available, please upload copies:

Drop files here or

Max. file size: 32 MB.

Part 2 - Requirements and Guidelines for Application

Please check each standard to acknowledge you have read and understand each guideline.

Consent - License(Required)

Applicants must have a full, unrestricted medical (or Allied Health Professional) license in the state in which they practice.(Required)

Consent - Reprimands(Required)

Licenses to practice must have been free of administrative fines, reprimands, restrictions, sanctions, probations, or disciplinary actions during the past five (5) years for some contracts.(Required)

Consent - Residency(Required)

Applicants must have verifiable residency or fellowship training or be board certified (ABMS or AOA recognized) in the specialty in which they will be listed. If not board certified, providers should provide source of experience in the practicing specialty. This is a requirement for some payors before contract approval.(Required)

Consent - Sanctions(Required)

Applicants must be free of any sanctions from Medicare or Medicaid.(Required)

Consent - Insurance(Required)

Applicants must have verifiable malpractice insurance in place. The following minimum amounts are required: MD/DO/PA $500k/$1m; AHP $500k/$500k; GROUP $1m/$3m(Required)

Consent - Malpractice(Required)

Applicants must provide a clear picture of the clinical aspects of malpractice cases in which they have been involved. Look back years vary by payor, all cases must be explained, although many will look only at the past five (5) years for any cases opened, closed.(Required)

Consent - Specialty Networks(Required)

Applicants who are in a specialty that qualify to admit and treat patients must have privileges at a network hospital or provide a letter of who will admit and treat their hospital patients.(Required)

Licensure

1. Has your license, registration, or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration of certification board?(Required)

Yes

If yes, please explain:

2. Has there been any challenge to your licensure, registration or certification?(Required)

Yes

If yes, please explain:

Hospital Privileges and Other Affiliations

3. Have your clinical privileges or medical staff membership at any hospital or healthcare institution, voluntarily or involuntarily, ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical record when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board?(Required)

Yes

If yes, please explain:

4. Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?(Required)

Yes

If yes, please explain:

5. Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)?(Required)

Yes

If yes, please explain:

Education, Training and Board Certification

6. Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign?(Required)

Yes

If yes, please explain:

7. Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?(Required)

Yes

If yes, please explain:

8. Have any of your board certifications or eligibility ever been revoked?(Required)

Yes

If yes, please explain:

9. Have you ever chosen not to re-certify or voluntarily surrendered your board certification while under investigation?(Required)

Yes

If yes, please explain:

DEA or CDS

10. Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s) or authorization(s) ever been challenged, denied, suspended, revoked, restricted, denied renewal, or voluntarily or involuntarily relinquished?(Required)

Yes

If yes, please explain:

Medicare, Medicaid or other Governmental Program Participation

11. Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified, or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs?(Required)

Yes

If yes, please explain:

Other Sanctions or Investigations

12. Are you currently the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid program, or any other private , federal or state health program or a defendant in any civil action that is reasonably related to your qualifications, competence, functions, or duties as a medical professional for alleged fraud, an act of violence, child abuse or a sexual offence or sexual misconduct?(Required)

Yes

If yes, please explain:

13. To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?(Required)

Yes

If yes, please explain:

14. Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)?(Required)

Yes

If yes, please explain:

15. Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted, disciplined or resigned in exchange for no investigation or adverse action within the last ten years for sexual harassment or other illegal misconduct?(Required)

Yes

If yes, please explain:

16. Are you currently being investigated, or have you ever been sanctioned, reprimanded, or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation or in exchange for no investigation by a hospital or healthcare facility of any military agency?(Required)

Yes

If yes, please explain:

Professional Liability Insurance Information and Claims History

17. Has your professional liability coverage ever been cancelled, restricted, declined, or not renewed by the carrier based on your individual liability history?(Required)

Yes

If yes, please explain:

18. Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional liability insurance carrier, based on your individual liability history?(Required)

Yes

If yes, please explain:

Malpractice Claims History

19. Have you had any professional liability actions (pending, settled, arbitrated, mediated, or litigated) within the past 10 years? If yes, provide information for each case.(Required)

Yes

If yes, please explain:

20. Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony?(Required)

Yes

If yes, please explain:

Criminal/Civil History

21. In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offence or sexual misconduct?(Required)

Yes

If yes, please explain:

22. Have you ever been court-martialed for actions related to your duties as a medical professional?(Required)

Yes

If yes, please explain:

23. Are you currently engaged in the illegal use of drugs? (Current means sufficiently recent to justify a reasonable belief that the use of drug may have an ongoing impact on one’s ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. Illegal use of drugs refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C.812.22. It does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the controlled Substances Act or other provision of Federal law. The term does include, however, the unlawful use of prescription-controlled substances.)(Required)

Yes

If yes, please explain:

24. Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety?(Required)

Yes

If yes, please explain:

25. Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients?(Required)

Yes

If yes, please explain:

26. Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonable accommodation?(Required)

Yes

If yes, please explain:

27. Has a final adverse action ever been imposed against the applicant under any current or former name or business activity?(Required)

Yes

If yes, please explain:

I understand this form must be completed and submitted to Berkeley and Associates before applicants for medicare and/or medicaid will be submitted to the plans.(Required)

I agree

Consent - Residency(Required)

Consent - Malpractice(Required)

{all_fields}

New Provider Application

Attention Providers

New Provider Application

Personal Information

Practice Information

Behavioral Health Information

PT / OT / ST Information

Credentials

Scripts

Insurance

Part 2 - Requirements and Guidelines for Application

Licensure

Hospital Privileges and Other Affiliations

Education, Training and Board Certification

DEA or CDS

Medicare, Medicaid or other Governmental Program Participation

Other Sanctions or Investigations

Professional Liability Insurance Information and Claims History

Malpractice Claims History

Criminal/Civil History

If you have questions about the on-boarding, please contact our office at 405-849-4016. We are happy to help!

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