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The Mississippi Participating Application form is a crucial document for physicians seeking to participate in managed care entities in Mississippi. This application collects essential information regarding a physician's practice, education, and work history. Completing the form accurately is vital for ensuring compliance and facilitating the application process.

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Content Overview

The Mississippi Participating Application form is a critical document for physicians seeking to engage with managed care entities in the state. This comprehensive application serves multiple purposes, including the original application for new physicians and reappointment for those already participating. It requires detailed information about the applicant's practice, educational background, licensure, and work history. Physicians must provide personal identifying information, including their name, contact details, and citizenship status. Additionally, the form mandates the submission of essential documents such as state medical licenses, liability insurance certifications, and curriculum vitae. The application also gathers information regarding the physician's practice location, office hours, and any affiliations with medical groups or networks. Furthermore, it addresses the physician's specialties, clinical services offered, and any ownership interests in medical-related organizations. This form is designed to ensure that all participating physicians meet the standards set by managed care entities while facilitating a streamlined process for both the applicant and the reviewing organization.

	CONFIDENTIAL/PROPRIETARY
Please check one:	Mississippi Participating Physician
Original Application	Application

Reappointment

This application is submitted to:_______________________________, herein, this Managed Care Entity 1.

SECTION A.

Practice, Educational, Licensure and Work History Information

I. INSTRUCTIONS

This form should be typed or legibly printed in black ink. If more space is needed than provided on original, attach additional sheets and reference the questions being answered. Please do not use abbreviations when completing the application. If an item in the application does not apply to you, write N/A in the box provided. Current copies of the following documents must be submitted with this application.

z State Medical License(s)	z Face Sheet of Professional Liability Policy or Certification
z DEA Certificate	z Curriculum Vitae
z Board Certification (if applicable)	z ECFMG (if applicable)

II. IDENTIFYING INFORMATION

Last Name:

First:

Middle:

Is there any other name under which you have been known (AKA/Maiden Name)? Name(s):

Home Mailing Address:

City:

State:

ZIP:

Home Telephone Number:

E-Mail Address:

Home Fax Number:

Pager Number:

Birthday Date:

Birth Place (City/State/Country):

Citizenship (If not a United States citizen, please include a copy of

Alien Registration Card).

Social Security #:

Gender 2 :

Male

Female

Race/Ethnicity 2

Specialty:

(voluntary):

Subspecialties:

Internal Medicine

III. PRACTICE INFORMATION

Practice Name (if applicable):

Department Name (if Hospital based):

Primary Office Street Address:

Primary Office Mailing Address if different from Street Address:

City:

State:

County:

Zip:

City:

State:

County:

Zip:

Telephone Number:

FAX Number:

Office Manager/Administrator:

Telephone Number:

Fax Number:

Name Affiliated with Tax ID Number:

Federal Tax ID Number:

1As used in the information Release/Acknowledgements Section of this application, the term “this Managed Care Entity” shall refer to

the entity to which the application is submitted as identified above.

2 This information will be used for consumer information purposes only.
Mississippi Participating Physician Application – 11/99	Page 1 of 12

Secondary Office Street Address:

City:

State:

ZIP:

Office Manager/Administrator:

Telephone Number:

FAX Number:

Name Affiliated with Tax ID Number:

Federal Tax ID Number:

Tertiary Office Street Address:

City:

State:

ZIP:

Office Manager/Administrator:

Telephone Number:

(

)

FAX Number:

(

)

Name Affiliated with Tax ID Number:

Federal Tax ID Number:

Handicap Access:

24 Hour Coverage:

Yes

Will you accept new patients?

Back office Telephone Number:

Yes

(

)

Please identify other networks in which you participate:

Please identify other networks from which you have been denied admission or de-selected:

Name of Network

Address

Reason for Denial or Deselection

Do you have ownership in any health or medical related organization, e.g., laboratory, home health care agency, radiology facility,

lithotrips, mobile testing, MRI, etc?	Yes	No
If Yes, please list:
If Yes, please list:


Medical Group(s) / IPA(s) Affiliation:
Medical Group(s) / IPA(s) Affiliation:


Do you intend to serve as a primary care provider?		Yes	No	Please check all that apply:
Do you intend to serve as a specialist?		Yes	No	Solo Practice	Single Specialty
If Yes, please list specialty(s):				Group Practice	Multi Specialty
Do you employ any allied health professionals (e.g. nurse practitioners, physician assistants, psychologists, etc.)?						Yes	No
If so, please list:
Name:			Type of Provider:			License Number:

______________________________________ _______________________________________________________________________

______________________________________ __________________________________________________ _____________________

______________________________________ ___________________________________________________ _____________________


Do you personally employ any physicians? (Do Not include physicians that are employed by the medical group)		Yes	No
Name:	Mississippi Medical License Number:

	_________________________________________________________________	_____________________________________________
	_________________________________________________________________	_____________________________________________
	_________________________________________________________________	____________________________________________

Mississippi Participating Physician Application – 11/99		Page 2 of 12

Please list any clinical services you perform that are not typically associated with your specialty:

Please list any clinical services you do not perform that are typically associated with your specialty:

Is your practice limited to certain ages?

If Yes, specify limitations:

Yes

Do you participate in EDI (electronic date interchange)?

Yes

Do you use a practice management system/software: Yes

If so, which Network?

If so, which one?

What type of anesthesia do you provide in your group/office?

Local

Regional

Conscious Sedation

General

None

Other (please specify):

___________________

Has your office received any of the following accreditation’s, certifications, or licensures?

American Association for Accreditation of Ambulatory Surgery Facilities (AAASF)

Medicare Certification

Mississippi Department of Health Licensure

Other:

IV. BILLING INFORMATION

Billing Company:

Street Address:

City:

State:

ZIP:

Contact:

Telephone Number:

Name Affiliated with Tax ID Number:

Federal Tax ID Number:

V. OFFICE HOURS – Please indicate the hours your office is open:

Monday	Tuesday	Wednesday	Thursday	Friday
24 HOUR	24 HOUR	24 HOUR	24 HOUR	24 HOUR
COVERAGE	COVERAGE	COVERAGE	COVERAGE	COVERAGE

Saturday

24HOUR COVERAGE

Sunday

24HOUR COVERAGE

Holidays

24HOUR COVERAGE

VI. COVERAGE OF PRACTICE (List your answering service and covering physicians by name. Attach additional sheets if necessary. Reference this section number and title)

Answering Service Company:

Telephone Number: ( )

Fax Number: ( )

Mailing Address:

City:

State:

ZIP:

Covering Physician’s Name:

Telephone Number:

(

)

Covering Physician’s Name:

Telephone Number:

(

)

Covering Physician’s Name:

Telephone Number:

(

)

Covering Physician’s Name:

Telephone Number:

(

)

If you do not have hospital privileges, please provide written plan for continuity of care:

Mississippi Participating Physician Application – 11/99

Page 3 of 12

VII. FOREIGN LANGUAGES SPOKEN


	Fluently by Physician:			Fluently by Staff:
	Fluently by Physician:			Fluently by Staff:

VIII. LABORATORY SERVICES

If you provide direct laboratory services, please indicate the TIN utilized and provide Clinical Laboratory Information Act (CLIA) information. Attach a copy of your CLIA certificate or waiver if you have one.

Tax ID #:

Billing Name:

Type of Service Provided:

Do you have a CLIA Certificate?

Do you have a CLIA waiver?

Yes

Certificate Number:

Certificate Expiration Date:

IX. MEDICAL/PROFESSIONAL EDUCATION

(Attach additional sheets if necessary. Reference this

section number and title.)

Medical School:

Degree Received:

Date of Graduation (mm/yy)

Mailing Address:

City:

State & Country:

ZIP:

Medical/Professional School:

Degree Received:

Date of Graduation (mm/yy)

Mailing Address:

City:

State & Country

ZIP:

INTERNSHIP/PGYI (Attach additional sheets if necessary, Reference this section number and title.)

Institution:

Program Director:

Mailing Address:

City:

State & Country:

ZIP:

Type of Internship:

Specialty:

From: (mm/yy)

To: (mm/yy)

XI.

RESIDENCES/FELLOWSHIPS (Attach additional sheets if necessary. Reference this section

number and title.)

Include residencies, fellowships, preceptorships, teaching appointments (indicate whether clinical or academic). And postgraduate education in chronological order, giving name, address, city, state, country, zip code and dates. Include all programs you attended, whether or not completed.

Institution:

Program Director:

Mailing Address:

City:

State & Country:

ZIP:

Type of Training (e.g. residency, etc)

Specialty:

From: (mm/yy)

To: (mm/yy)

Did you successfully complete the program?

Yes

No (If “No”, please explain on separate sheet.)

Mississippi Participating Physician Application – 11/99

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Institution:		Program Director:


Mailing Address:		City:
Mailing Address:		City:

State & Country:

ZIP:

Type of Training (e.g. residency, etc)

Specialty:

From: (mm/yy)

To: (mm/yy)

Did you successfully complete the program?

Yes

(If “No”, please explain on separate sheet.)

Institution:

Program Director:

Mailing Address:

City:

State:

ZIP:

Type of Training (e.g. residency, etc)

Specialty:

From: (mm/yy)

To: (mm/yy)

Did you successfully complete the program?

Yes

(If “No”, please explain on separate sheet.)

XII. BOARD CERTIFICATION (Attach copies of documents.)

Include certifications by board(s) which are duly organized and recognized by: z a member board of the American Board of Medical Specialties

z a member board of the American Osteopathic Association

z a board or association with an Accreditation Council for Graduate Medical Education of American Osteopathic Association approved post graduate training that provides complete training in that specialty or subspecialty.

Name of Issuing Board:

Specialty:

Certification Number:

Date Certified/ Rectified:

Expiration Date (if any):

Have you applied for board certification other than those indicated above?

Yes No

If so, list board(s) and date(s):

If not certified, describe your intent for certification, if any, and date of admissibility for certification on separate sheet.

Have you taken or failed a board exam?		If Yes, Provide details.
Yes	No

XIII. OTHER CERTIFICATIONS (e.g. Fluoroscopy, Radiography, etc.) (Attach additional sheets if necessary.

		Reference this section number and title.)
Type:	Number:		Expiration Date:
Type:

Type:	Number:		Expiration Date:
Type:

XIV. MEDICAL LICENSURE/REGISTRATIONS (Attach copies of documents)

Mississippi State Medical License Number:

Issue Date:

Expiration Date:

Active:

Yes

Drug Enforcement Administration (DEA) Registration Number:

Expiration Date:

Unlimited?

Yes

No If “No”, please explain on separate sheet

Controlled Dangerous Substances Certificate (CDS) (if applicable):

Expiration Date:

Mississippi Participating Physician Application – 11/99

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ECFMG Number (applicable to foreign medical graduates):

Visa Number:

Medicare UPIN/National Physician Identifier (NPI):

Mississippi Medicare Number:

Mississippi Medicaid Number:

XV. ALL OTHER STATE MEDICAL LICENSES – List all Medical licenses now or Previously Held. (Attach additional sheets if necessary. Reference this section number and title.)

State

State:

License Number:	Expiration Date:	Active:
		Yes	No
License Number:	Expiration Date:	Active:
		Yes	No
License Number:	Expiration Date:	Active:
		Yes	No
		Yes	No

XVI. PROFESSIONAL ORGANIZATIONS

Please list county, state or national medical societies, or other professional organizations or societies of which you are a member or applicant.

ORGANIZATION NAME	Applicant	Member

Are you an Officer or Director of any of the professional organizations listed above?
If Yes, please list:	Yes	No

XVII. PROFESSIONAL LIABILITY (Attach copy of professional liability policy or certification face sheet.)

Current Insurance Carrier:

Policy Number:

Original effective date:

Mailing Address:

City:

State & Country:

ZIP:

Telephone Number:

Fax Number:

( )

Per Claim Amount: $

Aggregate Amount: $

Expiration Date:

Please explain any surcharges to your professional liability coverage on a separate sheet. Reference this section number and title.

If you have had professional liability carriers in the last five years other than the one listed above, please list them below.

Name of Carrier:

Policy # :

From: (mm/yy)

To: (mm/yy)

Mailing Address:

City:

State and Country::

ZIP:

Name of Carrier:

Policy # :

From: (mm/yy)

To: (mm/yy)

Mailing Address:

City:

State and Country:

ZIP:

Mississippi Participating Physician Application – 11/99

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Name of Carrier:

Policy # :

From: (mm/yy)

To: (mm/yy)

Mailing Address:

City:

State & Country:

ZIP:

Name of Carrier:

Policy # :

From: (mm/yy)

To: (mm/yy)

Mailing Address:

City:

State & Country:

ZIP:

XVII. CURRENT HOSPITAL AND OTHER INSTITUTIONAL AFFILIATIONS

Please list in (A) in reverse chronological order, with the most current affiliation(s) first, all institutions with which you are currently affiliated. List previous affiliations during the past ten years in (B). Include hospitals, surgery centers, institutions, corporations, military assignments, or government agencies.

A. CURRENT AFFILIATIONS (Attach additional sheets if necessary. Reference this section number and title.)

Name and Mailing Address of Primary Admitting Hospital:

City:

State:

ZIP:

Department/Status (Active, provisional, courtesy, etc.):

Appointment Date:

Name and Mailing Address of Other Hospital/Institution:

City:

State:

ZIP:

Department/Status (Active, provisional, courtesy, etc.):

Appointment Date:

Name and Mailing Address of Other Hospital/Institution:

City:

State:

ZIP:

Department/Status (Active, provisional, courtesy, etc)

Appointment Date:

If you do not have hospital privileges, please explain.

B. PREVIOUS AFFILIATIONS (Limit to last ten years. Attach additional sheets if necessary. Reference this section number and title.)

Name and Mailing Address of Other Hospital/Institution:

City:

State:

ZIP:

From: (mm/yy)

To: (mm/yy)

Reason for Leaving:

Name and Mailing Address of Other Hospital/Institution:

City:

State:

ZIP:

From: (mm/yy)

To: (mm/yy)

Reason for Leaving:

Name and Mailing Address of other Hospital/institution:

City:

State:

ZIP:

From: (mm/yy)

To: (mm/yy)

Reason for Leaving:

Mississippi Participating Physician Application – 11/99

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Name and Mailing Address of Other Hospital/Institution:

City:

State:

ZIP:

From: (mm/yy)

To: (mm/yy)

Reason for Leaving:

XIX. PEER REFERENCES

List three professional references, preferably from your specialty area. Do not list relatives, current partners or associates in practice. If possible, include at least one member from the Medical Staff of each facility at which you have privileges. Do not include program directors previously listed under post graduate training and education in Section X.

NOTE: References must be from individuals who are directly familiar with your work, either via direct clinical observation or through a close working relationship.

Name of Reference:

Specialty:

Telephone Number:

Mailing Address:

City:

State:

ZIP:

Name of Reference:

Specialty:

Telephone Number:

Mailing Address:

City:

State:

ZIP:

Name of Reference:

Specialty:

Telephone Number:

Mailing Address:

City:

State:

ZIP:

XX. WORK HISTORY (Attach additional sheets if necessary. Reference this section number and title.)

Chronologically list all work history for at least the past five years (use extra sheets if necessary). This information must be complete. A curriculum vitae is sufficient provided it is current and contains all information requested below. Please explain any gaps in professional work history on a separate page.

Current Practice:

Contact Name:

Telephone Number:

Fax Number:

Mailing Address:

City:

State:

ZIP:

From: (mm/yy)

To: (mm/yy)

Name of Practice/Employer:

Contact Name:

Telephone Number:

Fax Number:

(

)

Mailing Address:

City:

State:

ZIP:

From: (mm/yy)

To: (mm/yy)

Mississippi Participating Physician Application – 11/99

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Name of Practice/Employer:	Contact Name:	Telephone Number:
Name of Practice/Employer:	Contact Name:	Telephone Number:
		(	)
		(	)

		Fax Number:
		Fax Number:
		(	)
		(	)
Mailing Address:		City:
Mailing Address:		City:

State:

ZIP:

From: (mm/yy)

To: (mm/yy)

Section B.

Professional Liability Action Explanation

Please complete this section for each pending, settled, or otherwise concluded professional liability lawsuit or arbitration filed and served against you, in which you were named a party in the past five (5) years, whether the lawsuit or arbitration is pending, settled or otherwise concluded, and whether or not any payment was made on your behalf by any insurer, company, hospital, or other entity. All questions must be answered completely in order to avoid delay in expediting your application. If there is more than one professional liability lawsuit or arbitration action, please photocopy this Section B prior to completing, and complete a separate form for each lawsuit.

I. CASE INFORMATION

City, County and State where lawsuit filed:

Court case number, if known:

Date of alleged incident serving as basis for the lawsuit/arbitration:

Date Suit Filed:

Sex of patient:

Age of patient:

Location of Incident:
	Hospital	My office	Other doctor’s office	Surgery Center
Other, (please specify)	__________________________________________________________________________________

Your relationship to Patient (Attending Physician, Surgeon, Assistant, Consulting, etc.):


Allegation:
Allegation:

Is/was there any insurance company or other liability protection company or organization providing coverage/defense of the lawsuit or

arbitration action?

Yes

If Yes, please provide company name, contact person, phone number, location and claim identification number of insurance company or other liability protection company or organization.

_________________________________________________________________________________________________________________

If you would like us to contact your attorney regarding any of the above, please provide attorney(s) name(s) and phone number(s). Please fax this document to your attorney to serve as your authorization:

Name: ____________________________________________________ Phone Number: _________________________________

Name: ____________________________________________________ Phone Number: __________________________________

II. WHAT IS THE STATUS OF THE LAWSUIT/ARBITRATION DESCRIBED ABOVE? (CIRCLE ONE)

Lawsuit/arbitration still ongoing, unresolved.
Lawsuit/arbitration still ongoing, unresolved.
Judgement rendered and payment was made on my behalf.	Amount paid on my behalf:	_______________________
Judgement rendered and I was found not liable.
Judgement rendered and I was found not liable.
Lawsuit/arbitration settled and payment made on my behalf.	Amount paid on my behalf:	________________________

Lawsuit/arbitration settled, no judgement rendered, no payment made on my behalf.

Summarize the circumstances giving rise to the action. If the action involves patient care, provide a narrative, with adequate clinical detail, including your description of your care and treatment of the patient. If more space is needed, attach additional sheet(s). Include: (1) condition and diagnosis at time of incident. (2) dates and description of treatment rendered, and (3) condition of patient subsequent to treatment. Please print.

Mississippi Participating Physician Application – 11/99

Page 9 of 12

SUMMARY

SECTION C.

Certification

I certify that the information in Section A and B of this application and any attached documents (including my curriculum-vitae if attached) is true, current, correct and complete to the best of my knowledge and belief and is furnished in good faith. I understand that intentionally withholding or omitting material information or intentionally submitting material false or misleading information may result in denial of my application or termination of my privileges, employment or physician participation agreement. I agree that the Managed Care Entity to which this application is submitted, its representatives, and any individuals or entities providing information to this Managed Care Entity in good faith shall not be liable, to the fullest extent provided by law, for any act or occasion related to the evaluation or verification contained in this Mississippi Participating Physician Application. In order for participating Managed Care Entities or Healthcare Organizations to evaluate my application for participation in and/or my continued participation in those organizations, I hereby give permission to release to this Managed Care Entity information about my medical malpractice insurance coverage and malpractice claims history. This authorization is expressly contingent upon my understanding that the information provided will be maintained in a confidential manner and will be shared only in the context of legitimate credentialing and peer review activities. This authorization is valid unless and until it is revoked by me in writing. I authorize the attorneys listed in Section B, Page 9, to discuss any information regarding the subject case with this Managed Care Entity.

Print Name Here: ___________________________________________________________________________

Physician Signature: ____________________________________________________________ Date: __________________________

(Stamped Signature Is not Acceptable)

Mississippi Participating Physician Application – 11/99

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Get Mississippi Participating Application File

Fact Name	Description
Application Purpose	The Mississippi Participating Application form is used for physicians to apply for participation in managed care entities.
Governing Law	This form is governed by Mississippi state laws regarding medical practice and managed care regulations.
Required Documents	Applicants must submit current copies of their state medical license, professional liability policy, DEA certificate, and curriculum vitae, among other documents.
Confidentiality	The form is marked as confidential/proprietary, ensuring that submitted information is protected.
Submission Instructions	Applicants should type or print the form in black ink and avoid using abbreviations. If additional space is needed, they should attach extra sheets.

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