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Blank North Carolina Department Of Insurance PDF Form

The North Carolina Department of Insurance Uniform Application is a crucial form for health care practitioners seeking to participate in health benefit plans. This application, mandated by North Carolina General Statute 58-3-230, ensures that insurers credential providers fairly and consistently. If you are ready to take the next step, fill out the form by clicking the button below.

Article Guide

The North Carolina Department of Insurance Uniform Application to Participate as a Health Care Practitioner is an essential tool for healthcare providers seeking to join insurance networks in the state. This form, approved by the Department of Insurance, is designed to streamline the credentialing process for insurers offering health benefit plans. It ensures that all necessary information is collected in a standardized manner, thus facilitating efficient evaluation and approval. Applicants must provide comprehensive demographic and personal data, including their name, date of birth, and type of practice. They also need to specify their areas of clinical expertise and the populations they serve. Along with the application, several supporting documents must be submitted, such as copies of state licenses, current DEA certificates, and proof of professional liability insurance. Each section of the form is structured to gather pertinent information while allowing for the inclusion of additional details when necessary. It is crucial for applicants to complete all sections accurately and to attach any required documentation to avoid delays in processing. This form not only helps maintain high standards in healthcare delivery but also protects both providers and patients by ensuring that practitioners meet the necessary qualifications to provide care.

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North Carolina Department of Insurance

Uniform Application

To Participate as a Health

Care Practitioner

Note: Please send completed applications directly to the

organizations with which you seek to contract.

The following application is a form approved by the North Carolina Department of Insurance, in accordance with North Carolina General Statute 58-3-230. Every insurer that provides a health benefit plan and credentials providers for its network is required to use this form and the insurer may not require an applicant to submit information that is not required by this form Only the Commissioner of Insurance is authorized to make changes, deletions or additions to this form.

June 2005

Page 1

INSTRUCTIONS

Before submitting the Application, make sure you have completed the following: Include an answer in all spaces. Indicate "N/A", if the question is not applicable. The provider has signed and dated the last page of the Application.

Before submitting the Application, make sure you have enclosed the following, if applicable: Copy of the provider's original state(s) license(s) and current registration.

Copy of current DEA certificate. (Must have a valid date and refer to current address.) Copy of South Carolina Controlled Drug Substance Certificate and DEA information.

Copy of the face sheet of your current professional liability insurance policy, indicating by name, provider(s) covered, coverage amounts, effective date, expiration date, and policy number. Attach previous carrier face sheet.

Proof of professional liability insurance for non-physician providers who care for patients in your practice. Copy of certificate from the Specialty Board.

Copy of Educational Commission of Foreign Medical Graduate Certificate- ECFMG. Letter(s) of reference, recommendation, and/or oversight, if required.

Copy of Curriculum Vitae or work history after graduation from Medical, Dental or other professional school

(CV must account for any gaps of 90 days or more).

Copy of CLIA (Clinical Laboratory Improvement Amendments) /ACR (American College of Radiology). Copy of W-9 Form.

Examples of documentation to attach to this application:

June 2005

Page 2

A.DEMOGRAPHIC AND PERSONAL DATA:

Name of Applicant:

	(Last Name)	(First Name)			(Middle Name)	(Maiden)

Date of Birth:			Place of Birth:

Social Security Number:			Sex:	Male	Female


Type of Practice:	Primary Care:			Specialist:

(Primary Specialty)				(Secondary Specialty)

Please Identify Areas of Clinical Expertise:

What population(s) do you treat (e.g. geriatric, all ages):

Name of Practice:

Primary Office Address (If you maintain more than one office, list each office, address, and hours of operation)

Practice Name:

Address:

(Street)(City)(County) (State) (Zip)

Handicapped Accessible?		YES	NO	Office Phone:			Fax:

E-mail address:

Accepting New Patients?		YES	NO	Restrictions:
				(Please list or indicate none)
Office Hours:
Monday	Tuesday		Wednesday		Thursday	Friday	Saturday	Sunday

Secondary Office Address

Practice Name:

Address:

(Street)(City)(County) (State) (Zip)

Handicapped Accessible?		YES	NO	Office Phone:			Fax:

E-mail address:

Accepting New Patients?		YES	NO	Restrictions:
				(Please list or indicate none)
Office Hours:
Monday	Tuesday		Wednesday		Thursday	Friday	Saturday	Sunday

June 2005

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A. DEMOGRAPHIC AND PERSONAL DATA (Continued)

Additional Office Address or Billing Address, if different (check one)

Billing

Office

Name:

Address:

(Street)(City)(County) (State) (Zip)

Handicapped Accessible?		YES	NO	Office Phone: xxx-xxx-xxxx/xxxx			Fax: xxx-xxx-xxxx/xxxx
Accepting New Patients?		YES	NO	Restrictions:
				(Please list or indicate none)
Office Hours:
Monday	Tuesday		Wednesday		Thursday	Friday	Saturday	Sunday

6.Name other provider(s) in your practice (if not enough space, please attach additional sheet):

7.Do nurse practitioners, physician assistants, midwives, social workers, or other non-physician providers provide care to

patients in your practice?	YES		NO

(If yes, please attach proof of professional liability insurance and proof of employment for those individuals)

Name and address of provider(s) who share call with you (if not enough space, please attach additional sheet):

Name:	Name:

Address:	Address:

10.

Arrangements for 24 hour/7 day coverage:

Administrative Contact:	(Title)	xxx-xxx-xxx/xxxx
(Name)	(Title)	(Telephone)

11.IRS requires reimbursement be made payable to name of practice affiliated with Federal Tax ID Number:

Federal Tax ID Number:

Name (if different from practice name):

Billing Address (if different from practice address):

12.

13.

UPIN Number:	Medicare/Medicaid Number:	/

National Provider Identifier (NPI):


DEA Number:	Exp. Date:
(Attach copy to application)

June 2005

Page 4

A.DEMOGRAPHIC AND PERSONAL DATA (Continued)

COMPLETE ONLY IF LICENSED IN SOUTH CAROLINA

SC Controlled Drug Substance Certificate:

Expiration Date:

(Attach a copy to application)

14.

Provide the following information for each state in which you are currently or were previously licensed to Practice (If not enough space please attach additional sheet)

STATE	DATE OF LICENSE	LICENSE NUMBER	STATUS	EXPIRATION
			Active, Inactive, Suspended	DATE

PLEASE ATTACH A COPY OF EACH STATE LICENSE CERTIFICATE

15.

Certification of Specialty Boards as applicable:

a.If you are certified by a specialty board, indicate name of board and date of certificate.

		Date Certified:		Exp. Date:
	(Primary Specialty Board)
		Date Certified:		Exp. Date:
	(Secondary Specialty Board)
b..
b..	Are you listed in the American Board of Medical specialists? YES		NO

c.If you have applied to a specialty board for examination, give the name of board and the date of scheduled examination. Date:

d. If you have not applied to a specialty board, please explain:

June 2005

Page 5

A. DEMOGRAPHIC AND PERSONAL DATA (Continued)

16.

List the dates of all current professional memberships in societies, including state and county societies:

FROMTO

17.

List all hospitals where you currently have privileges and indicate the type and status of those privileges:


(Type: active, admitting, associate, consulting, courtesy.		Status: pending, provisional, suspended, temporary, visiting)

Hospital	Privilege and Status of Privilege		Estimated % of Admission

(primary admitting facility)

18.

If you do not have admitting privileges, who admits for you?

Name:Name:

Address:Address:

Phone:

June 2005

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B.EDUCATION AND PRACTICE HISTORY

Medical, Dental, or other Professional School Attended:

Institution:

Address:

(Street)	(City)		(State)	(Zip)

Degree:		From:	To:

Please attach Educational Commission of Foreign Medical Graduate Certificate – (ECFMG), if applicable.

Internship

Institution:

Address:

(Street)	(City)		(State)		(Zip)

Specialty:		From: xx/xx/xxxx		To:	xx/xx/xxxx

Residency

Institution:

Address:

(Street)	(City)		(State)		(Zip)

Specialty:		From: xx/xx/xxxx		To:	xx/xx/xxxx

Other Residency / Fellowship – (specify)

Institution:

Address:

(Street)	(City)		(State)		(Zip)

Specialty:		From: xx/xx/xxxx		To:	xx/xx/xxxx

June 2005

Page 7

B. EDUCATION AND PRACTICE HISTORY (Continued)

List work history since beginning of medical, dental, or other professional school; please be specific.

(If not enough space, please attach additional sheet)

FROMTO

(Current Practice)

(Previous Practice)

List other training and/or education (including CME) within the last three years, if applicable.

Have you involuntarily or voluntarily withdrawn or been suspended from any internship, residency or fellowship training program? Please explain:

Please explain any incident(s) in which you have involuntarily or voluntarily withdrawn your application for appointment, clinical privileges or reappointment before a decision was made by a hospital or healthcare facility’s governing board.

June 2005

Page 8

C.PROFESSIONAL INFORMATION

Please check yes or no for the following questions. Please complete the attached Supplemental Form for any questions to which you answer “yes”. Also please sign and date this application. If this application does not have the provider’s signature, it cannot be accepted.

1.	Has your license to practice in any jurisdiction ever been limited, restricted, reduced, suspended,	Y	N
	voluntarily surrendered, revoked, denied or not renewed; have you ever been reprimanded by a state
	licensing agency; or are any of these actions pending with respect to your license; are you under
	investigation by any licensing or regulatory agency? (If yes, please complete Supplemental Question
	No. 1.)

2.	Has your professional employment or membership in a professional organization ever been subject	Y	N
	to disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed,
	or voluntarily relinquished during or under threat of termination for any reason? (If yes, please
	complete Supplemental Question No.2.)

3.	Has your Drug Enforcement Agency registration or other controlled substance authorization ever	Y	N
	been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily
	surrendered or limited your registration during or under the threat of an investigation or are any
	such actions pending? (If yes, please complete Supplemental Question No.3.)

4.	Have you ever been sanctioned or suspended by Medicare or Medicaid? (If yes, please complete	Y	N
	Supplemental Question No.4.)

5.	To your knowledge, have you ever been reported to the National Practitioner Data Bank or the	Y	N
	North/South
	Carolina Board of Medical Examiners? (If yes, please complete Supplemental Question No.5.)

6.	Have you ever been convicted of a felony or misdemeanor, or are you under investigation with	Y	N
	respect to such conduct? (If yes, please complete Supplemental Question No.6.)

7.	Has a professional liability claim been assessed against you in the past five years, or are there any	Y	N
	professional liability cases pending against you? (If yes, please complete Supplemental Question
	No.7.)

8.	Has any liability insurance carrier canceled, refused coverage, or rated up because of unusual risk or	Y	N
	have any procedures been excluded from your coverage? (If yes, please complete Supplemental
	Question No. 8.)

9.	Have you ever practiced without liability coverage? (If yes, please complete Supplemental Question	Y	N
	No.9.)

10.	Do you currently have any medical, chemical dependency or psychiatric conditions that might	Y	N
	adversely affect your ability to practice medicine or surgery or to perform the essential functions of
	your position? (If yes, please complete Supplemental Question No.10.)

11.	Have your Hospital and/or Clinic privileges ever been limited, restricted, reduced, suspended,	Y	N
	revoked, denied, not renewed, or have you voluntarily surrendered or limited your privileges during
	or under the threat of an investigation or are any such actions pending? (If yes, please complete
	Supplemental Question No. 11).

June 2005

Page 9

SUPPLEMENTAL FORM

Provider Name:

Provider ID#

(if applicable)

1. License Limited, Reprimanded, etc.

List State(s) where action took place:

Date(s) License revoked, suspended, etc.

From xx/xx/xxxx

To xx/xx/xxxx

Please explain:

2. Employment/Membership Suspended, Limited, etc.

List State(s) where action took place:

List Professional Organization:

Please explain:

3. Drug Enforcement Agency (DEA) Explanation.

List State(s) where action took place:

Please explain:

June 2005

Page 10

➤ PDF File

Form Specifications

Fact Name	Details
Form Title	Uniform Application To Participate as a Health Care Practitioner
Governing Law	North Carolina General Statute 58-3-230
Submission Requirement	Completed applications must be sent directly to the organizations with which the applicant seeks to contract.
Insurer Obligation	Every insurer providing a health benefit plan must use this form for credentialing providers.
Form Modification Authority	Only the Commissioner of Insurance can make changes to this form.
Application Instructions	Applicants must answer all questions and indicate "N/A" for non-applicable items.

North Carolina Department Of Insurance: Usage Guidelines

Completing the North Carolina Department of Insurance Uniform Application to Participate as a Health Care Practitioner requires careful attention to detail. The following steps outline the process to ensure that all necessary information is accurately provided. Once the application is filled out, it should be submitted directly to the organizations with which the applicant seeks to contract.

Obtain the North Carolina Department of Insurance Uniform Application form.
Fill in all spaces on the form. If a question does not apply, indicate "N/A."
Provide the applicant's name, date of birth, place of birth, and social security number in the demographic section.
Specify the type of practice, including primary care and any specialties.
List the name of the practice and the primary office address, including street, city, county, state, and zip code.
Indicate whether the office is handicapped accessible and provide the office phone number, email address, and fax number.
State if the practice is accepting new patients and note any restrictions.
Detail office hours for each day of the week.
If applicable, provide information for any secondary office addresses, including the same details as above.
List any other providers in the practice, and include proof of professional liability insurance for non-physician providers, if applicable.
Provide the name and address of providers who share call responsibilities.
Outline arrangements for 24-hour/7-day coverage.
Designate an administrative contact, including their name, title, and telephone number.
Fill in the Federal Tax ID number and any other relevant billing information, including UPIN and Medicare/Medicaid numbers.
Provide the DEA number and its expiration date, attaching a copy of the DEA certificate to the application.
Ensure the last page of the application is signed and dated by the provider.
Gather and attach any required documentation, such as copies of licenses, certificates, and letters of reference.
Review the completed application for accuracy before submission.
Submit the completed application and all attachments to the appropriate organizations.

Your Questions, Answered

What is the purpose of the North Carolina Department of Insurance Uniform Application?

The North Carolina Department of Insurance Uniform Application is designed for health care practitioners who wish to participate in health benefit plans. This application ensures that all necessary information is collected in a standardized format. It is required by insurers that credential providers for their networks. By using this form, insurers can maintain compliance with North Carolina law, specifically General Statute 58-3-230.

What should I include when submitting the application?

When submitting the application, it’s important to ensure that all sections are completed. If a question does not apply to you, indicate that by writing "N/A." Additionally, you must sign and date the last page of the application. Depending on your specific situation, you may also need to include supporting documents such as copies of your state license, current DEA certificate, professional liability insurance policy, and any relevant certifications. Make sure to review the checklist provided in the instructions to confirm that you have included everything necessary for a complete application.

Who should I send the completed application to?

You should send your completed application directly to the organization with which you are seeking to contract. This means that each insurer may have different submission processes, so it's best to check their specific requirements. Ensure that you follow their guidelines to avoid any delays in your application process.

Can changes be made to the application form after it has been issued?

No, only the Commissioner of Insurance has the authority to make changes, deletions, or additions to the application form. If you believe that any updates or changes are necessary, you will need to wait for official revisions from the Commissioner. It's essential to use the most current version of the form to ensure compliance with regulations.

Common mistakes

Failing to complete all required fields. It is essential to provide an answer for every question on the form. If a question does not apply, simply indicate "N/A" instead of leaving it blank.
Not including necessary documentation. Applicants often overlook the requirement to attach copies of important documents such as state licenses, DEA certificates, and proof of professional liability insurance.
Forgetting to sign and date the application. The last page of the application must be signed and dated by the provider. An unsigned application will be considered incomplete.
Neglecting to list all practice locations. If a provider has multiple offices, each one should be listed with its address and operating hours. Incomplete information can delay processing.
Not providing accurate contact information. Ensure that the office phone number, email address, and fax number are correct. Incorrect information can hinder communication from the insurance organization.
Overlooking the need for proof of employment for non-physician providers. If there are nurse practitioners or other non-physician providers in the practice, proof of their professional liability insurance and employment must be attached.
Submitting the application without verifying all information. Before sending, double-check that all information is accurate and complete. Errors can lead to delays or denial of the application.

Documents used along the form

When applying to participate as a health care practitioner in North Carolina, it is essential to gather all necessary documentation. This ensures a smooth application process and compliance with state regulations. Below is a list of forms and documents that are commonly used alongside the North Carolina Department of Insurance form.

W-9 Form: This form is used to provide your taxpayer identification number to the payer. It is essential for tax purposes and ensures that payments are reported correctly to the IRS.
Curriculum Vitae (CV): A detailed document that outlines your professional history, education, and qualifications. It should include any gaps in your employment history and provide a comprehensive overview of your career.
Professional Liability Insurance Certificate: This document proves that you have liability insurance coverage. It should detail the policy number, coverage amounts, and the names of the providers covered.
DEA Certificate: A copy of your Drug Enforcement Administration registration is necessary for practitioners who prescribe controlled substances. It ensures compliance with federal regulations.
State License Copies: You must provide copies of your original state license(s) and current registration. This verifies your qualifications to practice in North Carolina.
Board Certification: Documentation proving that you are board certified in your specialty. This is often required by insurers to validate your expertise.
Letters of Reference: These letters provide endorsements from colleagues or supervisors, highlighting your qualifications and professional conduct. They can strengthen your application significantly.

Collecting these documents can seem overwhelming, but each one plays a crucial role in your application. Ensure that everything is accurate and complete before submission to avoid delays in the credentialing process.

Similar forms

The North Carolina Department of Insurance Uniform Application To Participate as a Health Care Practitioner shares similarities with several other important documents used in the healthcare field. Each of these documents serves a specific purpose, often related to provider credentialing and regulatory compliance. Here is a list of ten documents that are comparable:

State Medical License Application: This document is required for healthcare practitioners to obtain a license to practice medicine in a specific state. Like the North Carolina form, it collects demographic information and verifies qualifications.
National Provider Identifier (NPI) Application: Healthcare providers must apply for an NPI, which is a unique identification number. Similar to the North Carolina application, it requires personal and practice-related information.
Credentialing Application for Health Plans: Health insurance companies require this application to assess a provider's qualifications. It includes similar information about education, training, and practice history.
Medicare Enrollment Application (CMS-855I): This form is necessary for providers to enroll in Medicare. It also asks for detailed personal and professional information, paralleling the North Carolina application.
Controlled Substance Registration Application: Practitioners must apply for a state-controlled substance registration to prescribe medications. This document, like the North Carolina form, necessitates proof of credentials and practice details.
Professional Liability Insurance Application: Providers must complete this application to obtain malpractice insurance. It similarly requires information about the applicant's practice and previous claims history.
Board Certification Application: This application is submitted to obtain board certification in a specialty. It includes educational background and clinical experience, akin to the North Carolina Department of Insurance form.
Clinical Laboratory Improvement Amendments (CLIA) Application: Laboratories must apply for CLIA certification to operate legally. This application collects information on laboratory practices and personnel, similar to the healthcare practitioner application.
Continuing Medical Education (CME) Credits Reporting Form: Physicians must report their completed CME credits for licensure renewal. This form requires documentation of educational activities, much like the proof of qualifications needed in the North Carolina application.
Employment Application for Healthcare Providers: This document is used by healthcare facilities to evaluate potential employees. It often requests similar demographic and professional information as the North Carolina form.

Dos and Don'ts

When filling out the North Carolina Department of Insurance form, there are important dos and don'ts to keep in mind. Following these guidelines will help ensure that your application is complete and processed efficiently.

Do answer all questions completely. If a question does not apply, indicate "N/A."
Do sign and date the last page of the application.
Do include copies of all required documents, such as your state license and DEA certificate.
Do ensure that your professional liability insurance information is accurate and up-to-date.
Do provide a complete Curriculum Vitae, accounting for any gaps in your work history.
Don't submit the application without reviewing it for completeness.
Don't forget to include proof of professional liability insurance for non-physician providers, if applicable.
Don't leave any sections blank; this can delay your application.
Don't submit documents that are not required by the form.
Don't forget to keep a copy of the completed application for your records.

By adhering to these guidelines, you can facilitate a smoother application process with the North Carolina Department of Insurance.

Misconceptions

Misconceptions about the North Carolina Department of Insurance form can lead to confusion and delays in the application process. Here are seven common misconceptions, along with clarifications to help applicants better understand the requirements.

The form is optional for all healthcare practitioners. Many believe that using the North Carolina Department of Insurance form is optional. In reality, every insurer providing a health benefit plan must use this form for credentialing healthcare providers.
Additional information can be requested by insurers. Some applicants think insurers can ask for extra information beyond what is listed on the form. However, insurers are not allowed to request any information that is not specified in the form.
Only physicians need to fill out this form. A common misconception is that only physicians are required to complete this application. In fact, all healthcare practitioners seeking to contract with insurers must submit this form, regardless of their specific profession.
The application can be submitted to the Department of Insurance. Some applicants mistakenly believe they should send their completed application to the North Carolina Department of Insurance. Instead, the application must be sent directly to the organizations with which the practitioner wishes to contract.
All documents must be submitted with the application. There is a belief that every listed document must accompany the application. While many documents are required, applicants should only submit those that are applicable to their situation.
Changes to the form can be made by anyone. Some individuals think that anyone can modify the application form. However, only the Commissioner of Insurance has the authority to make any changes, deletions, or additions to the form.
The application process is the same for all types of practitioners. Many assume that the application process is uniform for all healthcare practitioners. In reality, specific requirements may vary based on the type of practice and the services provided.

Understanding these misconceptions can help healthcare practitioners navigate the application process more effectively, ensuring they meet all necessary requirements without unnecessary delays.

Key takeaways

When filling out the North Carolina Department of Insurance form, keep these key takeaways in mind:

Complete Every Section: Ensure that all fields are filled out. If a question does not apply to you, write "N/A."
Required Attachments: Include all necessary documents, such as your state license, DEA certificate, and proof of liability insurance.
Sign and Date: Make sure the last page of the application is signed and dated by you before submission.
Submit Directly: Send the completed application to the organizations you wish to contract with, not to the Department of Insurance.
Stay Updated: Only the Commissioner of Insurance can make changes to the form. Ensure you’re using the most current version.