United Behavioral Health/US Behavioral Health ... - Ubhonline.com

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III. Please describe your coverage arrangements for patient emergencies 24 hours per day, seven days a week. (Advising patients to call 911 is not sufficient.) IV. Billing Address (If different from Primary Clinic/Office Address above) Name of Group/Clinic/Office Phone Number Billing Contact Address County Billing Contact Phone Number City State Zip V. Additional Office Location (Please make copies of page 2 for additional locations) Name of Group/Clinic/Office Federal Tax Id Number for this practice Address County Check name for this practice (for TIN above) City State Zip Your start date at this practice Daytime Phone Number Emergency/After Hours Phone Secure Fax Number (for patient info) Other Fax Number Office Contact Name Office Contact Phone Number Office Contact Fax Number Is this practice located in your home? ___ Yes ___ No Are you accepting new patients at this location? ___ Yes ___ No Do you follow HIPPA guidelines for privacy? ___ Yes ___ No Does this office meet state fire and safety codes? ___ Yes ___ No Are you available for evening appointments at this location? ___ Yes ___ No Are restrooms available for all patients at this location? ___ Yes ___ No Can another clinician access patient records in case of an emergency? ___ Yes ___ No Do you have emergency procedures in place in case of fire or natural disaster? ___Yes ___No Are you available for weekend appointments at this location? ___ Yes ___ No Do you have patient rights posted in your waiting room? ___ Yes ___ No Do you obtain and document consent for treatment (for MDs this includes consent for medications)? ___ Yes ___ No To ensure patient confidentiality are all medical records stored in locked cabinets? ___ Yes ___ No Is this location handicap/ wheelchair accessible? ___ Yes ___ No Is this location accessible via public transportation? ___ Yes ___ No Do you have written material explaining after-hours coverage? ___ Yes ___ No Are you able to treat hearing impaired or deaf patients in this location? ___ Yes ___ No Can individual session content be heard by other patients? ___ Yes ___ No @UBH/USBHPC/LEI 6/2004 Page 2
VI. Current Hospital Admitting Privileges Name of Hospital Type of Privileges Address City State Zip Phone Name of Hospital Type of Privileges Address City State Zip Phone Name of Hospital Type of Privileges Address City State Zip Phone VII. Professional Liability Insurance (Clinician must be named as insured on the policy or attachment) Name of Carrier Policy Number Address City State Zip Coverage Limits (Occurrence/Aggregate) __ Occurrence __ Claims Made Dates of Coverage Years with Carrier VIII. Work History – Please provide a chronological work history for the past 5 years including employment, selfemployment, clinical practice, service as an independent contractor, and military service. It is not necessary to duplicate education, internship, residency or fellowship information previously reported. Please explain any gaps in work history greater than 6 months. A Curriculum Vita may not be substituted for completion of this section. Current Practice/Employer Name (must match practice information on page 2) Start Date (MM/YYYY) End Date (MM/YYYY) Present City State Title or Professional Occupation Previous Practice/Employer Name Start Date (MM/YYYY) End Date (MM/YYYY) City State Title or Professional Occupation Previous Practice/Employer Name Start Date (MM/YYYY) End Date (MM/YYYY) City State Title or Professional Occupation Previous Practice/Employer Name Start Date (MM/YYYY) End Date (MM/YYYY) City State Title or Professional Occupation Previous Practice/Employer Name Start Date (MM/YYYY) End Date (MM/YYYY) City State Title or Professional Occupation Please provide an explanation for any gaps in work history greater than 6 months: Gap Dates: __________________ Explanation: _________________________________________________________________ (MM/YYYY to MM/YYYY) Gap Dates: __________________ Explanation: _________________________________________________________________ (MM/YYYY to MM/YYYY) @UBH/USBHPC/LEI 6/2004 Page 3
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Page 5 and 6: Areas of Clinical Expertise Continu
Page 7 and 8: PHYSICIAN SPECIALTY REQUIREMENTS (M
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United Behavioral Health/US Behavioral Health ... - Ubhonline.com

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