Contract Application Instructions

A W-9 form is required to identify the contracting entity before contract issuance.

W-9 must accompany Contract Application.

Please return application electronically as a Microsoft Word document or PDF

(FAXED COPIES WILL NOT BE ACCEPTED) to Daphyne Watson, Contracting Manager, at DWatson@chgsd.com. For questions regarding the application, please contact Maria Diaz at

(619) 498-6560.

*ALL APPLICABLE FIELDS MUST BE COMPLETED.

If seeing patients under the age of 21 years, please apply to CCS and CHDP.

http://www.dhcs.ca.gov/services/ccs/Pages/ProviderEnroll.aspx

REQUESTED BY: Practitioner CHG	NOTE:
A. CONTACT INFORMATION
DATE:	CONTACT E-MAIL:
CONTACT NAME:	TITLE:
CONTACT PHONE #:	CONTACT FAX #:
B. PRACTITIONER/GROUP INFORMATION
ORGANIZATION NAME: ORGANIZATION NPI #:	DBA:
PRACTITIONER(S): (If more than 1 practitioner and not credentialed, provide a roster with required data from Section C).	SPECIALTY: Plastic Surgery
SUBSPECIALTY:
TAX ID #:	NPI #:	Billing NPI #:
ADDRESS(ES):	LANGUAGES SPOKEN BY PRACTITIONER(S):
PHONE #:	FAX #:
MEDI-CAL PROGRAM ENROLLED? YES NO MEDICARE PROGRAM ENROLLED? YES NO	TREATS PATIENTS <18: YES NO TREATS PATIENTS 18 AND OVER YES NO (Must be CCS paneled if seeing patients under age 21)
CALIFORNIA CHILDREN SERVICES (CCS) PANELED? YES NO N/A	CHILD HEALTH AND DISABILITY PREVENTION (CHDP) CERTIFIED? YES NO N/A
OTHER MEDICAL GROUPS AND/OR HEALTH PLAN AFFILIATIONS? Explain:
CONTRACT TYPE: PCP Specialist Allied Health	CONTRACT: New Add LINE(S) OF BUSINESS: Medi-Cal Community y Más (HMO C-SNP) CommuniCare Advantage (HMO D-SNP)
ACCEPT STANDARD RATES? Yes NO (Medi-Cal Rates for Medi-Cal patients) (Medicare Rates for CMC patients)	TAXONOMY CODE(S):
TAXONOMY DESCRIPTION:
ONLINE TAXONOMY LOOK-UP VIA NPPS WEBSITE: https://npiregistry.cms.hhs.gov/
HOURS OF OPERATION: (PCP must meet 32 hours per week minimum per location)	ACCEPT SAME DAY APPOINTMENTS? Yes No
VIDEO TELEHEALTH: Yes NO	PHONE TELEHEALTH: Yes NO

SAN DIEGO COUNTY HOSPITAL PRIVILEGES (Please check all that apply): Not Applicable Alvarado Hospital Scripps Encinitas Sharp Coronado LTACH Palomar Medical Center Scripps Green Sharp Grossmont Select Hospital of SD Paradise Valley Hospital Scripps Hillcrest Sharp Mary Birch/Memorial Other Pomerado Hospital Scripps La Jolla Sharp - All Rady Children's San Diego Scripps - All Tri-City Medical Center Scripps Chula Vista Sharp Chula Vista UCSD/Thornton
SKILLED NURSING CENTER PRIVILEGES Please list:	SURGERY CENTER PRIVILEGES Please list:
SCOPE OF PRACTICE:
OFFER GENDER-AFFIRMING SERVICES: YES NO
COMMENTS/BACKGROUND:
C. PRACTITIONER CREDENTIALING STATUS (FOR PHYSICIANS ONLY)
Credentialing Status: CHG ACTIVE NOT ACTIVE WITH CHG (If not active, complete the following questions)	LICENSE #: CAQH #:
DATE OF BIRTH:
MEDICAL/GRADUATE DEGREE FROM:	DATE RECEIVED:
BOARD CERTIFICATION:
BOARD:	ISSUED:	EXPIRES:	SPECIALTY:
D. ELECTRONIC DATA INTERCHANGE (EDI)
DOES ORGANIZATION USE A PRACTICE MANAGEMENT SYSTEM? YES IF YES, WHICH ONE? NO	BILLING SERVICE CONTACT INFORMATION: CONTACT NAME: E-MAIL: PHONE #: FAX #:
EDI READY (ANSI 837 FORMAT)? YES NO
UPON CONTRACT APPROVAL, ACCEPTANCE OF PAYMENT VIA EFT (Electronic Funds Transfer) WILL BE REQUIRED
WILL YOU BE SUBMITTING CLAIMS DIRECTLY TO CHG? YES NO (If no, complete following question) CLEARINGHOUSE NAME (If any):
FOR CHG USE ONLY
DIRECTOR APPROVED: YES NO	NETWORK COMMITTEE RECOMMENDATION YES NO	PRE-CRED: YES NO
COO APPROVED: YES NO Initials:__________ Date:________________	OPS INFORMED: YES NO Date:_________________