MEDICAID N.C. - FORMS
1. Exclusion Sanction questionnaire (A-K): Answer all questions: if you answer YES,
you
must
attach a list with the date of each incident and also supporting documentation
for each
2. On the data page I will add my information as the Office Administrator and this will
allow me to set up your enrollment. Skip to the bottom to Approver section:
Print your name
List your current email address and phone number
Check the “Provider” box
Sign/date
Do not fill in any other fields
3. Consent to Release Information
Sign/date
If you have an Office Administrator, provide the name and contact here, do not fill in the form:
Full
Name
(correct
spelling):
Telephone (work/primary contact#):
Primary/active
if
known:
Return all forms to my attention:
Carolinas Medical Center-NorthEast
NEPN / Jennifer Lambert
845 Church Street N, Suite 310
Concord, NC 28025-4375
Exclusion Sanction Information
This section is only required if the new OA has not been added to the provider record as managing employee in NCTracks. The answers apply to the new OA as well as the provider and any other Managing Employees listed on the provider record.
IMPORTANT: If you answer “Yes” to any sanction question, you must attach supporting documentation
that includes an explanation for each question as well as a complete copy of the applicable criminal complaint, consent order, documentation, and/or final disposition clearly indicating the final resolution. Submitting a written explanation in lieu of supporting documentation may result in the denial of this request.
A. Has the applicant, managing employees, owners, or agents ever been convicted of a felony, had adjudication withheld on a felony, pled no contest to a felony, or entered pre-trial agreement for a felony?
Yes No
B. Has the applicant, managing employees, owners, or agents ever had disciplinary action taken against any business or professional license held in this or any other state, or has your license to practice ever been restricted, reduced, or revoked in this or any other state or been previously found by a licensing, certifying, or professional standards board or agency to have violated the standards or conditions relating to licensure or certification or the quality of services provided, or entered into a consent order issued by a licensing, certifying or professional standards board or agency?
Yes No
North Carolina Replacement Medicaid Management Information System (MMIS)
Page 1 of 2
C. Has the applicant, managing employees, owners, or agents ever been denied enrollment, been suspended, excluded, terminated or involuntary withdrawn from Medicare, Medicaid, or any other government or private health care insurance program in any state, or been employed by a corporation, business , or professional association that has ever been suspended, excluded, terminated, or
involuntarily withdrawn from Medicare, Medicaid, or any other government or private health care or health insurance program in any state?
Yes No
D. Has the applicant, managing employees, owners, or agents ever had suspended payments from Medicare or Medicaid in any state, or been employed by a corporation, business , or professional association that ever had suspended payments from Medicare or Medicaid in any state?
Yes No
E. Has the applicant, managing employees, owners, or agents ever had civil monetary penalties levied by Medicare, Medicaid, or other State or Federal Agency or Program, including the Division of Health Service Regulation (DHSR), even if the fine(s) have been paid in full?
Yes No
F. Does the applicant, managing employees, owners, or agents owe money to Medicare or Medicaid that has not been paid?
Yes No
G. Has the applicant, managing employees, owners, or agents ever been convicted under federal or state law of a criminal offense related to the neglect or abuse of a patient in connection with the delivery of any health care goods or services?
H. Has the applicant, managing employees, owners, or agents ever been convicted under federal or state law of a criminal offense relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance?
Yes No
I. Has the applicant, managing employees, owners, or agents ever been convicted of a criminal offense relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct?
Yes No
J. Has the applicant, managing employees, owners, or agents ever been found to have violated federal or state laws, rules, or regulations governing North Carolina’s Medicaid program or any other state’s Medicaid program or any other publicly funded federal or state health care or health insurance program and been sanction accordingly?
Yes No
K. Has the applicant, managing employees, owners, or agents ever been convicted of an offense against the law other than a minor traffic violation?
NPI/Atypical ID
Please provide the NPI/Atypical ID for the individual provider record to be changed. Only one NPI or ATypical ID may be submitted per form.
NPI/Atypical ID:
Current Office Administrator
Provide the full name and NCID of the current office administrator to be replaced. If you do not know the current OA NCID, leave the field blank.
Full Name: NCID:
New Office Administrator
Complete the following fields for the new Office Administrator. All fields are required. The new OA NCID must be an active NCID in the North Carolina Identity Management (NCID) system.
Full Name: NCID:
Business Email Address: Primary Phone Number:
Relationship: Provider (Self) Managing Employee
DOB SSN:
Approver
Complete the following information for the approver The approver must be an owner or managing employee listed on the provider profile in NCTracks.
Attestation: By signing this form, I confirm the information contained on this form is true, accurate, complete and current, as of the date on the form. I do hereby attest that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.
Full Name:
Business Email Address: Primary Phone Number:
Relationship: Provider Managing Employee
Signature: Date
Page 1 of 1 North Carolina Replacement Medicaid
Management Information System (MMIS)
Yes No
If the new OA is listed as an owner or managing emp oyee for another provider in NCTracks, select "Yes" and provide the NPI. Otherwise, select "No".If the new OA is already listed in NCTracks as an owner or managing employee for another provider it may not be necessary to run a new background check if the check has been performed within the past six months.
If the new OA is currently listed on the NCTracks provider record for this NPI as an owner managing emp oyee, select "Yes". Otherwise, select "No" and provide the DOB and SSN of the new OA so that a background investigation can be completed.
Yes No
Jennifer S. Lambert
JLAMBE09
North Carolina Department of Health and Human Services
CONSENT TO RELEASE INFORMATION
I understand that the North Carolina Department of Health and Human Services (DHHS) and its representatives are responsible for the evaluation of my professional training, experience, professional conduct, and judgment. All information submitted by me or on my behalf pursuant to this Consent to Release Information is true and complete to the best of my knowledge and belief. I fully understand that any misstatement in or omission related thereto may constitute cause for the summary dismissal/denial of such participation in the DHHS Program. I understand and agree that as an applicant for participation in the DHHS Program, I have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications.
I hereby authorize DHHS and its representatives to contact and/or consult with any persons, entities or institutions (including, but not limited to, hospitals, HMOs, PPOs, other group practices and professional liability carriers) which I have been affiliated, have used for liability insurance or who may have information relevant to my character and professional competence and qualifications, whether or not such persons or institutions are listed as references by me. I consent to the release and communication of information and documents between DHHS and its representatives and persons, entities or institutions in jurisdictions in which I have trained, resided, practiced, or applied for professional licensure, privileges or membership in plans for the purpose of evaluation of my professional training, experience, character, conduct, ethics and judgment, and to determine professional liability insurance and/or malpractice insurance claims history.
I also authorize and direct persons contacted by DHHS and its representatives to provide such information regarding my character and/or professional competence and qualifications, my professional liability insurance and/or malpractice insurance claims history to representatives of the Program and I understand in doing so, I am waiving my confidentiality rights to this information. I release and hold harmless from liability all persons, entities, or institutions acting in good faith and without malice for acts performed in gathering or exchanging information in this credentialing process. This release and hold harmless provision applies to all persons, entities and institutions who will provide and/or receive, as part of the Program’s credentialing process, information which may relate to my past or present physical and/or mental condition, including substance abuse, alcohol dependency and mental health information. I further authorize the release of the above information or any other information obtained from the application by a credentialing verification organization (CVO) to any health care organization designated by me or one that has entered into an agreement with the CVO where I currently have, am currently applying, or in the future will be applying for participation. I also authorize the CVO or DHHS to allow my file to be reviewed by the organizations' state or national accrediting and licensing bodies.
NC DHHS Provider Enrollment | CSC EVC Center rev. 07/01/2013 P.O. Box 300020 | Raleigh, NC 27622‐8020
False Claims Act Attestation
As agent, managing employee, owner, partner, or operator of a North Carolina Medicaid provider, I certify understanding of the provisions and requirements established in section §1902(a)(68) of the Social Security Act that relate to Employee Education About False Claims Recovery.
