Credentialing Information ChecklistCOMPANY INFORMATIONThe Following information is required form credentialing and contracting with providers. Please complete requested information below:I. General InformationCorporate Contact and AddressComapny:DBA:Contact Name: Corporate Address: City: State: Zipcode: Phone Number:Fax Number:No. of Employees:Email Address:NPI Number:Website:EIN:Site Location (if other than corporate address)First Name:Last Name:Corporate Address: City: State: Zip Code: Phone Number Fax Number: Remittance Address (if other than corporate address)First Name:Last Name:Address: City: State: Zip Code: Phone Number Fax Number: Correspondence Contact Information (if other than corporate address)First Name:Last Name:Address: City: State: Zip Code: Phone Number Fax Number: Email Address Website: Medical or Laboratory DirectorFirst Name:Last Name:Corporate Address: City: State: Zip Code: Phone Number Fax Number: Email Address: SS# DOB: City of Birth: Country of Birth: Driver's License Number: State: Effective Date: Contact Name for Enrollment Application Shall be SenergeneFirst Name:Last Name:Corporate Address : City: State: Zip Code: Phone Number Fax Number: Email Address: II. Provider InformationNational Providers Identifiers(NPI):Tax Identification Number:Medicare Provider Number(PTAN):Medicaid Providers Numbers:Taxonomy code:CLIA:Business Permit:All State Laboratory Permit:StateLab Pemit No.StateLab Permit No.StateLab Permit No.StateLab Permit No.StateLab Permit No.StateLab Permit No.StateLab Permit No.StateLab Permit No.General Liability Insurance Per Occurrence:General Liability Insurance Per Aggregate:Professional Liability Insurance Per Occurrence:Professional Liability Insurance Per Aggregate:III. Entity InformationIndividualsPublicLimited Liability Corporation(LIC)PartnershipCorporationSole ProprietorshipOwnership: EntityEntity Name:Effective Date:Address: City: State : Zip Code : Phone Number Email Address: EIN: Ownership: Individual1. First Name:Last Name:Address: City: State : Zip Code: Phone Number Fax Number: Email Address: SS# DOB: City of Birth: Country of Birth: Driver's License Number: State: Effective Date: 2. First Name:Last Name:Address: City: State : Zip Code: Phone Number Fax Number: Email Address: SS# DOB: City of Birth: Country of Birth: Driver's License Number: State: Effective Date: 3. First Name:Last Name:Address: City: State : Zip Code: Phone Number Fax Number: Email Address: SS# DOB: City of Birth: Country of Birth: Driver's License Number: State: Effective Date: If 5% Ownership or More, Please listName % Ownership Has any family or household members(s) of the entity who has ownership or control interest in the entity ever 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?YesNoManaging DirectorsFirst Name:Last Name:Position:First Name:Last Name:Position:First Name:Last Name:Position:First Name:Last Name:Position:First Name:Last Name:Position:Exclusion / Sanction Information :Has the entity ever had any adverse legal actions imposed by Medicare, Medicaid, or any other Federal or State agancy or program, or any licensing or certification agency? Attach a copy of any relevent final dispositions.NoYes(If "yes", please attach details)Has any member of your entity ever been placed on prepayment review status by Medicaid?NoYes(If "yes", please attach details)Has any member of your entity had a recoupment of over $5,000 in any 18-Month period?NoYes(If "yes", please attach details)IV Financial Information :Electronic Funds Transfer (EFT)Bank Name:Contact InformationAddress : City : State : Zip Code : Phone Number Fax Number: Email Address: Acccount Number :Routing Number :Name of individual with signature authority : Electronic Capabilites :Please provide the following:Name of the Clearinghouse and Vendor used for claim submission : Electronic Health Records Vendors : Please EMAIL copies of the following to Senergance:Laboratory CLIA PermitProof of Medicare PaymentCMS SurveyAccrediting Body SurveyLaboratory Director's PermitOrigional NPI LetterMedicare LetterCertificate of Authority Insurance (displaying insurance)Completed W-9Copies of Owners Driver's LicensePlease send the following reports : Aging Report 30-60 90-120 (past 2 Years)Transcations Detail Report with Billed Amt. Allowed Amt. Paid Amt, Outstanding, Bad Debt Write-Off (past 2 years)Test Menu or Master Pricing include CPT Codes, List Prices and Self-Pay Price by service or productPlease list below your Medical Provider number of any state in which you are currently enrolled:Providers No.Providers No.ALNEAKNVAZNHARNJCANMCONYCTNCDENDFLOHGAOKHIORIDPAILRIINSCIASDKSTNKYTXLAUTMEVTMDVAMAWAMIWVMNWIMSWYMO
