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Baxer Tech Support` $Specialized Therapy Associates, LLCLeslie A. Baxer Normal.dotm Tech Support2@F#@k`@p<@p<՜.+,D՜.+,\M 0Caolan80 2tFKQ442V^VXbrZVG$ AToVVV Specialized Therapy Associates, LLC 83 Summit Avenue Hackensack, NJ 07601 (201) 488-6678 / (201) 342-1695 fax Email to:  HYPERLINK "mailto:personnel@specializedtherapy.com"personnel@specializedtherapy.com (Check One)____Job Application ____PPO Network Application Name: Last, First, M.I. (Jr., Sr., etc.) Title/Degree Any previous name(s)  NPI # (SSN if no NPI #) Date of Birth CAQH ID #  Type of Business (If applying as a group or PPO) Medical Group ________ IPA _________ Solo Practice __________ PHO ________ Other (i.e.  sole proprietorship, corporation, professional corporation, and limited liability company) _________________________________________________________________________________ Licensure Discipline State/License # Year Granted Expiration Date DEA Narcotics License # Year Granted DEA Expiration Date Mailing Address Residence or Primary Office Location: Please indicate  City, State, Zip Code Telephone Number Fax Number Pager/Cell Number  Coverage (Complete only for PPO Network Application) Do you have 24 hour telephone coverage? _____________ If so, what arrangements have you made?___________________________________________________________ Is this office handicap accessible? _________ Office hours at this location: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Are there arrangements for urgent care (same day response)? __________ Billing Address: Street Address (Complete only for PPO Network Application)  City, State, Zip Code  Tax ID # Office Administrator Prior Work History Place of Employment Position Reason for Leaving     Describe what did you like most about your prior places of employment? If you are applying for a management position, please describe your management philosophy? What is your current salary? What is your desired salary? What are your preferred locations to work? When are you able to start work? Are you able and willing to work evenings? Covering Practitioners (Complete only for PPO Network Application) List all covering practitioners: Name Telephone # Emergency Telephone # Street Address, City, State, Zip Code  Name Telephone # Emergency Telephone # Name Telephone # Emergency Telephone # Street Address, City, State, Zip Code  Name Telephone # Emergency Telephone # Name Telephone # Emergency Telephone # Street Address, City, State, Zip Code  Name Telephone # Emergency Telephone # Education School/Program Degree Year Granted    Continuing Education / Postgraduate Study / Board Certification (Attach copies of certificates and any additional information.) School or Board Certification Date Certification Granted Expiration Date School or Board Certification Date Certification Granted Expiration Date School or Board Certification Date Certification Granted Expiration Date Hospital Privileges Name and Address Privilege Type Privilege Status  Name and Address Privilege Type Privilege Status  Name and Address Privilege Type Privilege Status  Any previous hospital affiliations: Name and Address Privilege Type Privilege Status  Professional Memberships Association Dates of Active Membership    Malpractice Insurance Company Name (not agency)  Street Address  City, State, Zip Code Telephone # Policy #  Date first obtained Expiration Date  Coverage Limits: per occurrence aggregate  Type of coverage: claims made _____, occurrence _____, tail _____ List all previous insurance carriers with active dates   Medicare/Medicaid Do you accept Medicare assignment? _____ Do you accept Medicaid assignment? _____ Medicare UPIN # Medicaid # Medicare # Self Identifying Information (voluntary) Race Gender Religion Foreign Languages spoken References Name Relationship Telephone Number _________________________ _________________________ _______________________ _________________________ _________________________ _______________________ _________________________ _________________________ _______________________ _________________________ _________________________ _______________________ List the Insurance Provider Panels that you Participate: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Completed Applications for Job or for the PPO Network require the attachment of licenses, certifications, malpractice facesheet and any other relevant documents, such as, specialized training and board certifications. Please attach a copy of your CV. Feel free to offer a description of your professional areas of practice or any other information that you believe will distinguish your application to STA. Mail the original FORM with all supporting documents to STA, P O Box 3016, South Hackensack, New Jersey 07606 or supply the application along with your required attachments via email to personnel@specializedtherapy.com. You may also fax documents to 201-342-1695. Areas of expertise and training-must be listed on CV and must provide documentation of training. Choose areas of expertise and specialized training from the following list. Indicate years of experience in treating that disorder. ___adjustment disorders ___anxiety disorders ___bereavement/grief counseling ___chemical dependency ___depression ___eating disorders ___sexual identity orientation ___gay/lesbian issues ___HIV ___incest survivors ___men s issues ___multiple personality disorder ___personality disorders ___parenting ___post-traumatic stress disorder ___somatoform disorders ___women s issues ___ACOA ___ADD/ADHD ___borderline personality disorder ___child abuse ___elder abuse ___dissociative disorders ___domestic violence ___forensics ___geriatrics ___stage of life adjustments ___infertility ___learning disabilities ___mood disorders ___pain management ___phobias ___sexual abuse ___sexual dysfunction ___stress management ___neuropsychological disorders ___developmental delays ___ multicultural issues ___other _____________________________________________________________________________________________ Populations Served ___Infant ___Toddler ___Child ___Adolescent ___Adult ___Geriatric Treatment Modalities ___Individual ___Group ___Marital ___Family ___wellness ___biofeedback ___medication management ___psychological testing ___neuropsychological testing ___hypnosis ___workplace evaluation ___forensic evaluation ___mediation ___employee assistance ___critical incident stress debriefing ___analysis IMPORTANT. Please read carefully and completely before signing. I hereby certify that the information provided in this application is accurate and true. I understand that any information entered into this application which subsequently is found to be false could result in immediate dismissal from the STA PPO Network or from employment at STA. In order to evaluate my application for inclusion and continuing participation status in the STA PPO Network, in the event my application is accepted, I hereby give my permission to STA PPO, its affiliates, employees and agents to solicit information regarding my professional credentials and qualifications. Specifically included, but not limited to, in this consent are the following informational sources: professional state licensing boards, Medicare regulating agencies, and colleagues or chiefs of departments of a facility where I have practiced. Release and Authorization I authorize STA, LLC and its subsidiaries, affiliates, successors, employees and agents, to consult with hospitals, members of hospital medical staffs, professional liability carriers, managed care organizations and other persons or entities to obtain information concerning my qualifications, including without limitation my professional competence and conduct. I consent to the release to STA, LLC of any and all information that may be relevant to an evaluation of my qualifications, including information about disciplinary actions and information that might otherwise be considered confidential or privileged. I authorize STA, LLC to release this information, as well as quality assurance data relating to me, to health benefit plans owned, managed or administered by STA, LLC to medical groups, independent practice associations and similar entities contracting with said health plans, or as authorized under state or federal law or regulation. I release STA, LLC and any and all persons or entities providing information about me to STA, LLC from any and all liability connected with or arising from the release of such information, provided that such party(ies) was acting in good faith and without malice in evaluating my application and any decisions related to my application or credentialling status. I understand that I have the burden of providing adequate information to STA, LLC to demonstrate my qualifications. I understand and agree that any misstatement or material omission in this application will constitute grounds for rejection of my application or summary dismissal as a participating provider in any and all networks maintained by STA, LLC. If any material changes occur in the information I have provided in this application making such information no longer correct and complete or affecting my professional status, I understand and agree that it is my obligation to notify STA, LLC, its subsidiaries, affiliates, successors employees and agents within 10 days of said occurrence. Failure to comply with this obligation may constitute grounds of rejection of my application or summary dismissal as a participating provider in any and all networks maintain or managed by STA, LLC. I attest that the information contained in this application is true, correct and complete.  Signature of Provider Date PRACTICE ATTESTATION FORM Write your responses to each question. Have you ever had any adverse action taken or is any adverse action pending with respect to: -state license, certificate, or registration? -DEA registration or other applicable narcotic registration? -hospital or other health care facility staff membership or privileges? -professional organization membership? -Medicare, Medicaid, or any other governmental health program participations? -HMO, PPO, pho, phc, IPA or any prepaid health plan or managed care participation? -educational or training institution or program? -professional society or association? Do you have a medical condition, which in any way impairs or limits your ability to practice with reasonable skill and safety? If yes, are the limitations or impairments reduced or ameliorated due to receiving ongoing treatment, with or without medication, or participation in a monitoring program? If yes, are the limitations or impairments caused by your medical condition reduced or ameliorated because of the field of practice, the setting or the manner in which you have chosen to practice? Do you have any chronic communicable disease or other medical conditions that would pose a risk to the safety or well being of you patients? If you use chemical substances, does your use in any way impair or limit your ability to practice with reasonable skill and safety? Are you currently engaged in illegal use of controlled dangerous substances? Are you currently participating in a supervised rehabilitation program or professional assistance program which monitors you? Are you now or have you been involved in any malpractice action(s), including litigation, arbitration or mediation, regardless of the method or amount of the resultant outcome? Has payment to resolve or avoid any allegation(s) concerning your competence, conduct or quality of care (including but not limited to those which did not involve litigation, arbitration or mediation) ever been paid by you or on your behalf? If yes, attach the following information for each allegation, claim, suit, action, or settlement, whether open or closed, regardless of whether payment was made. Please obtain this information from your insurer or attorney, if necessary. -date and clinical details of the incident(s) leading to the allegation, claim, suit, action or settlement. Be specific. -date of filing, date of resolution and outcome (for example, settlement or award by an arbitrator, mediator, panel, judge, or jury) or, if not resolved, current status (for example, open, closed, in arbitration, etc.) -professional liability insurer involved -your status (for example, primary defendant, co-defendant, other) and the names of any other co-defendants Has your professional liability insurance or coverage been denied, suspended, canceled, lapsed, not renewed, special rated or experienced gaps? Have you been convicted of a crime or are you under indictment for an alleged crime? Have you been the subject of an administrative, civil or criminal complaint or investigation regarding sexual misconduct or child abuse? If yes, provide full details (including the plaintiff and court caption of any pending lawsuit). Are you presently a defendant in a malpractice, discrimination or professional liability lawsuit or proceeding or have you been placed on notice of such a potential lawsuit or proceeding yet to be filed which has not been reported in writing to STA, LLC? If you have been employed by or served as a clinician or other health care provider for military service, a hospital, a managed care plan or any other health care organization, was such relationship terminated by anyone other than yourself? LIST ALL INSURANCE PANELS FOR WHICH YOU ARE PRESENTLY CREDENTIALED AS AN IN NETWORK PROVIDER. PRINT NAME____________________________________________________ SIGNATURE AND DATE___________________________________________ Mail the original PRACTICE ATTESTATION FORM with all supporting documents to STA, P O Box 3016, South Hackensack, New Jersey 07606 or supply the application along with your required attachments via email to personnel@specializedtherapy.com. You may also fax documents to 201-342-1695. Specialized Therapy Associates, LLC Authorization to Release Records and Other Information I hereby authorize STA, LLC to request all of my records, personal recommendations, and other pertinent information with respect to my hospital privileges or my performance in medical school or as an intern, resident, or physician. I hereby authorize the hospital or institution or other institution or individual receiving such request to release such records and information to STA, LLC. I understand that all of the records and information provided will be available to the staff and to the administrations of STA, LLC in connection with consideration of my application. I understand and agree that all recommendations and disclosures or records of information will be privileged to the full extent permitted by law. I further agree not to bring any administrative proceeding or take any judicial action against STA, LLC or any person, hospital or institution providing, receiving or using any such material. Name (Print clearly) Signature Date Mail the original FORM with all supporting documents to STA, P O Box 3016, South Hackensack, New Jersey 07606 or supply the application along with your required attachments via email to personnel@specializedtherapy.com. You may also fax documents to 201-342-1695. Specialized Therapy Associates, LLC Authorization to Obtain Certificate of Insurance Name of Insured Office Address Policy Number Insurance Company (not Agent) Street Address City State Zip Code I hereby authorize the above-named insurance company to annually provide STA, LLC, 83 Summit Avenue, Hackensack, NJ 07601 with a copy of my Certificate of Insurance of professional liability coverage. In the event of any material change in, cancellation of, or failure to renew said coverage, I also authorize the above-named company to give written notice to STA, LLC. I hereby release from liability and agree to hold harmless said company and its representatives for the provision of such information to STA, LLC. Signature Date Mail the original FORM with all supporting documents to STA, P O Box 3016, South Hackensack, New Jersey 07606 or supply the application along with your required attachments via email to personnel@specializedtherapy.com. You may also fax documents to 201-342-1695. Specialized Therapy Associates, LLC Authorization to Obtain Proof of Licensure Name Address License Number Licensing Board/State Street Address City State Zip Code I hereby authorize the above-named licensing board to provide STA, LLC, 83 Summit Avenue, Hackensack, NJ 07601 with proof of licensure. In the event of any material change in, cancellation of, or failure to renew said license, I also authorize the above-named licensing board to give written notice to STA, LLC. I hereby release from liability and agree to hold harmless said licensing board and its representatives for the provision of such information to STA, LLC. Signature Date Mail the original FORM with all supporting documents to STA, P O Box 3016, South Hackensack, New Jersey 07606 or supply the application along with your required attachments via email to personnel@specializedtherapy.com. You may also fax documents to 201-342-1695. 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