Complete the Facility Application in Its Entirety

Facility/Organization Application Instructions In order to complete the facility/organization credentialing process, VI Equicare, Inc. requires the following CURRENT information/documentation. An application, which is not accompanied by all required documents noted in the checklist below, will cause a delay in the credentialing process. VI Equicare, Inc. has an established standard of 180 days to complete the entire credentialing process from receipt of completed application through final credentials decision. . Complete the Facility Application in its entirety. . Please type or print application in legible writing- prefer typed. . Review your application before signing and mailing. Incomplete applications will not be processed and will be returned to you resulting in a delay in the credentialing process. . Sign and date application. . Keep a copy of your application or your own file. . A Facility/Organization Application must be completed for each facility/organization. If you have multiple locations, please reproduce this application, as needed. Failure to accurately answer and/or falsifying any of the responses on this application will constitute cause for immediate and automatic denial of affiliation and/or termination of affiliation with VI Equicare, Inc.

The following information must be attached to Facility Application in order to complete the application and credentialing process. Only applications accompanied by ALL required documentation as noted on attached Facility Checklist will be processed.  Facility/Organization Application completed in its entirety and signed/dated;  Copy of all Current Facility/Organization Licenses/Certifications- including copy of Certificate of Need, if applicable;  Letter or Certificate from any/all Accrediting Organizations, if applicable; (e.g. JCAHO, CMS, CLIA, ACHC, CARF, etc.);  Current copy of Certificate(s) of Insurance- commercial and professional liability;  Original of W-9 Form;  Detailed list of services provided at facility and indicate whether performed in-house or by contract.

If you have any questions or need clarification regarding this application, please call the Credentialing Department at (340)774-5779.

Please mail completed Facility Application with all documentation to: VI Equicare, Inc. Attn: Credentialing Department P.O. Box 9620 St. Thomas, VI 00801

VI Equicare, Inc. 1 Revised: 11/1/2012

Facility/Organization Application

Facility Information: (A Separate Application Must Be Completed for Each Facility) Facility Name: ______d/b/a (if applicable):______

Type of Facility: Ambulatory Health Clinic Behavioral Health Facility Birthing Center Diagnostic Imaging Facility (circle one) DME Free Standing Surgical Center Free Standing Urgent Care/Emergency Center

Home Health Care Hospice Center Hospital Infertility Clinic Long Term Care Facility

Medical Transport Service Rehabilitative Therapy Facility Skilled Nursing

Other:______

Facility/Organization Address: ______

City: ______State:______Zip:______

Phone:______Fax:______

Billing Address:______

City:______State:______Zip:______

Tax Identification # (W-9 must be attached):______NPI #:______

Medicare #:______Medicaid #:______

Facility/Organization License/Registration Certificate #/Expiration Date:______

(Copy of current license/certificate must be attached)

Facility/Organization Contact Person:

Name/Title:______Phone:______e-mail______

Chief Administrator:

Name/Title:______Phone:______e-mail______

Medical Director:

Name/Specialty:______Phone:______e-mail______

Authorized Designee Initials ______

Hours/Days of Operation:

Sunday:______Monday:______

Tuesday:______Wednesday:______

Thursday:______Friday:______

Saturday:______

Does your facility/organization perform background checks on all employees? □ Yes □ No

If yes, what type?______

Professional Liability Insurance (Please attach a copy of current Certificate of Insurance and return with completed application.) (Include month, day and year for all dates)

Current Insurance Carrier:______

Mailing Address:______

City: ______State:______Zip:______

Phone Number:______Policy Effective Date:______Policy Number:______Policy Renewal Date:______Policy Retro Date:______Limits of Professional Liability: Occurrence______Aggregate______

Professional Liability Insurance-Continued PROFESSIONAL LIABILITY IF YOU ANSWER YES TO ANY OF THE FOLLOWING, PROVIDE A FULL EXPALNATION OF EACH CASE ON THE PROVIDED MALPRACTICE CLAIM DATA Have any malpractice claims, suits, settlements or arbitration proceedings been made against your facility/organization or staff within the past five (5) years? If yes, what is the total □ YES □ NO number?... ______

Total Pending Cases………………………………………………………….. ______

Total Dismissed/ Settled/ Closed with No Payment………………………... ______

Total Dismissed/ Settled/ Closed with Payment……………………………. ______□ YES □ NO Has your facility/organization ever had professional liability insurance cancelled, restricted, declined, or not renewed in the past five years?

*In addition to the Malpractice Claim Data Form for each case/claim/settlement/proceeding, please include ANY and ALL additional documentation available from third parties for cases closed during the past five (5) years from the date of the application. Please see the “Information Regarding 3rd Party Documentation for Malpractice Claims” insert for documentation VI Equicare, Inc. considers acceptable. Commercial General Liability Insurance (Please attach a copy of current Certificate of Insurance and return with completed application.) (Include month, day and year for all dates)

Current Insurance Carrier:______

Mailing Address:______

City: ______State:______Zip:______

Phone Number:______Policy Effective Date:______Policy Number:______Policy Renewal Date:______Policy Retro Date:______Limits of Professional Liability: Occurrence______Aggregate______COMMERCIAL GENERAL LIABILITY IF YOU ANSWER YES TO ANY OF THE FOLLOWING, PROVIDE A FULL EXPALNATION OF EACH CASE ON THE PROVIDED GENERAL LIABILITY CLAIM DATA Have any claims, suits, settlements or arbitration proceedings been made against your facility/organization or staff within the last five (5) years? If yes, what is the total number?... □ YES □ NO ______

Total Pending Cases………………………………………………………….. ______

Total Dismissed/ Settled/ Closed with No Payment………………………... ______

Total Dismissed/ Settled/ Closed with Payment……………………………. ______□ YES □ NO Has your facility/organization ever had general liability insurance cancelled, restricted, declined, or not renewed in the past five years?

*In addition to the General Liability Claim Data Form for each case/claim/settlement/proceeding, please include ANY and ALL additional documentation available from third parties for cases closed during the past five (5) years from the date of this application. Please see the “Information Regarding 3rd Party Documentation for General Liability Claims” insert for documentation VI Equicare, Inc. considers acceptable. VI Equicare, Inc. 4 Revised: 11/1/2012

General Information

Is facility/organization in good standing with the Department of Health and Department of Licensing and Consumer Affairs? ______

If no, please explain in an attachment.

Is facility/organization in good standing with federal regulatory bodies (if applicable)? ______

If no, please explain in an attachment.

Is facility/organization currently accredited? ______

If yes, what type of accreditation? ______

LIST ACCREDITATION(S) AND ATTACH COPIES OF MOST RECENT ACCREDITATION(S) BY JCAHO OR CMS. IF FACILITY IS NOT JACHO OR CMS ACCREDTED, A SITE VISIT WILL BE REQUIRED AND YOU MUST SUPPLY THE INFORMATION REQUESTED IN EXIHIBIT A.

If no, is facility/organization in the process of accreditation and what type? ______

Has the facility/organization had any of the following? (Please attach explanations if any of the following questions are answered “Yes”)

1. Debarments, revocations or suspensions as a Medicare or Medicaid provider? ______

2. Malpractice liability insurance cancellation in the past five years? ______

3. General liability insurance cancellation in the past five years? ______

4. Territory licensing investigations or actions? ______

5. Termination, sanction or penalization by the insurance carrier for the employees of the Virgin

Islands? ______

Authorized Designee Initials ______Quality/Utilization Review

1. Are the credentials and/or certificates of professional staff members and admitting physicians verified? ______

2. Is continuing education and/or recertification required of your staff? ______

3. Is there a formal patient grievance/resolution procedure? ______

4. Does this facility/organization have written policies and procedures? ______

I hereby attest, affirm and acknowledge all information that is provided in this application is true, correct, and complete to the best of my knowledge. I understand that I have the burden of providing adequate information to VI Equicare, Inc. or employees, agents, or successors in order to complete the initial credentialing process and any future recredentialing processes. I authorize VI Equicare, Inc., its employees, agents, and/or successors to consult with necessary persons or entities to obtain and/or verify the qualifications as listed in this application. I release VI Equicare, Inc., its employees and/or successors and their agents from any and all liability for their acts performed in good faith and without malice in obtaining information and evaluating this application. I understand and accept that VI Equicare, Inc. may conduct a site review of this facility. I authorize VI Equicare, Inc. to perform any such site review upon reasonable request.

______Signature of Chief Administrator or Authorized Designee Date

______Print Name of Chief Administrator or Authorized Designee

______Facility Name

______Address

______City, State, Zip Code

Any information stated in this application which is subsequently found to be false may result in the immediate termination of the facility contract between facility/organization and VI Equicare, Inc.

Authorized Designee Initials ______VI Equicare, Inc. 6 Revised: 11/1/2012

Exhibit A

(ONLY COMPLETE THIS IF FACILITY/ORGANOZATION IS NOT JCAHO OR CMS ACCREDITED)

List all physicians/clinical staff who provide services at this location. (Attach sheet if additional space needed) Physician/Clinical DOB SS# DEA# License#/Expir. Staff Name (e.g. MD, DO, LPN, DPM, and PA)

List all technologists at this location- attach copies of all certificates (Attach sheet if additional space needed) - Provide copy of facility policy for Technologists supervision by facility physician. Technologist Name CPR Cert. TB Cert. Mammo Accred ARRT #/Expir.

MALPRATICE CLAIM INFORMATION (Please make copies if additional forms are needed)

Claimant Name: ______

Location of Occurrence (city/state): ______

Date of Occurrence: ______

Provider Case Narrative (use separate paper and write ‘see attached narrative’ if necessary): ______

Claim Outcome: (check the appropriate outcome) ______Pending ______Withdrawn by Claimant ______Dismissed/Settled/Closed with no payment ______Dismissed/Settled/Closed with payment

Total Claim Payment (all defendants): $______Claim payment on your behalf: $______By Insurance Carrier: $______By Patient Compensation Fund (if applicable): $______

Provider Signature: ______

Print Name: ______

Date: ______

All of the above information is required ------Optional Information Insurance Carrier Information (name, policy number, contact): ______

Legal Counsel Contact Information: ______

3rd Party Documentation for Malpractice Claims

For each malpractice claim that was settled/dismissed/closed during the past five (5) years: Complete the “Malpractice Claim Information” form AND  Provide at least one of the following forms of 3rd party documentation  Correspondences must be on sender’s letterhead and include: . The plaintiff’s name (or identifying information) . Date of incident . Allegations Pending Claims:

 Legal Counsel Correspondence *In addition to above requirements, the letter must contain a statement that the “case is defensible”.

 Finalized Claims: (In addition to the above requirements, all letters must contain the outcome of the claim and total indemnity paid on your behalf)

 National Practitioner Data Bank Self-Query (Claims settled/closed within the past five (5) years) *Customer Service 800-767-6732 *https://icd.npdb-hipdb.com:663/ - ‘self-queries’ link *NPDB report cannot be older than ninety (90) days from the date you sign your application

 Final Court Order and / or Settlement Agreement *The Records Department in the county where the claim was filed can assist you in obtaining the Final Court Order and/ or Settlement Agreement.

 Insurance Company/ Legal Counsel Correspondence *Claims History/ Loss Run

 Facility/ Hospital/ Clinic Correspondence *The Risk Management and/ or Legal Department should be able to assist you in obtaining a letter form the Facility/Hospital/Clinic.

 United States Government Correspondence *If the claim occurred while working at a government facility and you were covered under the Federal Tort Claims Act, the Risk Management and/ or Legal Department should be able to assist you in obtaining a letter from the Facility/Hospital/Clinic.

3rd Party Documentation for Malpractice Claims-Cont’d

 Patient Compensation Fund Correspondence *If the claim occurred in a state in which you were enrolled in the Comp Fund, contact the Comp Fund to obtain a letter stating how much they paid on your behalf. Patient Compensation Fund correspondence will not be accepted as sole 3rd party documentation. One of the above must also be obtained.

At times, VI Equicare, Inc’s Risk Management team may require additional forms of 3rd party documentation for a single claim in the event that the originally submitted information is insufficient.

You may contact the Credentialing Department with any questions.

Thank you for your cooperation.

GENERAL LIABILITY CLAIM INFORMATION (Please make copies if additional forms are needed)

Claimant Name: ______

Location of Occurrence (city/state): ______

Date of Occurrence: ______

Provider Case Narrative (use separate paper and write ‘see attached narrative’ if necessary): ______

Claim Outcome: (check the appropriate outcome) ______Pending ______Withdrawn by Claimant ______Dismissed/Settled/Closed with no payment ______Dismissed/Settled/Closed with payment

Total Claim Payment (all defendants): $______Claim payment on your behalf: $______By Insurance Carrier: $______By Patient Compensation Fund (if applicable): $______

Provider Signature: ______

Print Name: ______

Date: ______

All of the above information is required ------Optional Information Insurance Carrier Information (name, policy number, contact): ______

Legal Counsel Contact Information: ______

3rd Party Documentation for General Liability Claims

For each general liability claim that was settled/dismissed/closed during the past five (5) years: Complete the “General Liability Claim Information” form AND  Provide at least one of the following forms of 3rd party documentation  Correspondences must be on sender’s letterhead and include: . The plaintiff’s name (or identifying information) . Date of incident . Allegations Pending Claims:

 Legal Counsel Correspondence *In addition to above requirements, the letter must contain a statement that the “case is defensible”.

 Finalized Claims: (In addition to the above requirements, all letters must contain the outcome of the claim and total indemnity paid on your behalf)

 Final Court Order and / or Settlement Agreement *The Records Department in the county where the claim was filed can assist you in obtaining the Final Court Order and/ or Settlement Agreement.

 Insurance Company/ Legal Counsel Correspondence *Claims History/ Loss Run

 Facility/ Hospital/ Clinic Correspondence *The Risk Management and/ or Legal Department should be able to assist you in obtaining a letter from the Facility/Hospital/Clinic.

 United States Government Correspondence *If the claim occurred while working at a government facility and you were covered under the Federal Tort Claims Act, the Risk Management and/ or Legal Department should be able to assist you in obtaining a letter from the Facility/Hospital/Clinic.

3rd Party Documentation for General Liability Claims-Cont’d

At times, VI Equicare, Inc’s Risk Management team may require additional forms of 3rd party documentation for a single claim in the event that the originally submitted information is insufficient.

You may contact the Credentialing Department with any questions.

Thank you for your cooperation.

Deadlines For Committee Dates

In order for your application to be presented to the Credentialing Committee, your application must be completed in its entirety and must be on file in the VI Equicare, Inc Credentialing Department’s office no later than the deadline dates below. Once your application is reviewed by the Credentialing Committee, it is in then submitted to the VI Equicare, Inc. Board of Directors for final approval.

Deadline Date Credentialing Committee Board Meeting Date Meeting Date

January 9, 2013 January 17, 2013 TBA

February 13, 2013 February 21, 2013 TBA

March 6, 2013 March 13, 2013 TBA

April 10, 2013 April 17, 2013 TBA

May 9, 2013 May 16, 2013 TBA

June 12, 2013 June 19, 2013 TBA

July 10, 2013 July 17, 2013 TBA

August 14, 2013 August 21, 2013 TBA

September 11, 2013 September 18, 2013 TBA

October 9, 2013 October 16, 2013 TBA

November 13, 2013 November 20, 2013 TBA

December 11, 2013 December 18, 2013 TBA