You use the Licensure, Certification, Permit & Grant page to add or edit an individual provider's license, certification, specialty, and taxonomy information to an enrollment application.
The Licensure, Certification, Permit & Grant page for Individual Provider Enrollment contains the following panels:
| Field | Description |
|---|---|
| To add a new specialty, click Add Specialty. Existing specialties, if any, are displayed in a table. To edit, in the Specialty List table, click the appropriate row. After changing or adding new specialties, on the Specialty action bar, click Save. | |
| Specialty |
Provider's specialty type. A specialty requires completion of the appropriate residency program, board certification, state certification, or eligibility. Examples: OB/GYN, Internal Medicine, Dental Health Aid Tech, etc. |
| Certification # | Provider certification number. |
| Certification Agency | Certification agency's name. |
| State | State in which specialty certification was issued. |
| Field | Description |
|---|---|
| To add a new taxonomy, click Add Taxonomy. Existing taxonomy codes, if any, are displayed in a table. To edit, in the Taxonomy table, click the appropriate row. After changing or adding new taxonomy codes, on the Taxonomy action bar, click Save. | |
| Taxonomy | The 10-digit/alpha taxonomy code of the provider. |
| Begin Date |
Date the taxonomy code became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| End Date |
Date the taxonomy code expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Field | Description |
|---|---|
| Are you a Dispensing Provider? | Select Yes or No to indicate if you are a dispensing provider. |
| The Dispensing Provider's practice location is 45 miles from a retail pharmacy. | Select Yes or No to indicate if the dispensing provider's practice location is 45 miles from a retail pharmacy. |
| The Dispensing Provider is not a covered entity under 42 U.S.C.256b or purchasing outpatient drugs under either the 340b program (section 602) or Federal Supply Schedule pricing (section 603). 7 AAC 145.410. | Select Yes or No to indicate that the dispensing provider is not a covered entity. |
| Field | Description |
|---|---|
| Are you an intern or a resident-in-training provider? | Select Yes or No to indicate if you are an intern or resident-in-training provider. |
| Field | Description |
|---|---|
| Are you a federal employee assigned to tribal hospital, tribal clinic, other type of tribal health care facility or program? | Select Yes or No to indicate if you are a federal employee assigned to a tribal hospital, tribal clinic, or other type of tribal health care facility or program. |
| Field | Description |
|---|---|
| Are you an employee of the hospital and provide services to patients in the hospital? | Select Yes or No to indicate if you are an employee of the hospital and provide services to patients in the hospital. |
| Do you receive a salary, a portion of collections, fringe benefits or deferred compensation from the hospital? | Select Yes or No to indicate if you receive a salary, a portion of collections, fringe benefits or deferred compensation from the hospital. |
| Is your malpractice insurance, continuing medical costs, or 30% or more of on-going professional business costs paid for by the hospital? | Select Yes or No to indicate if your malpractice insurance, continuing medical costs, or 30% or more of on-going professional business costs are paid for by the hospital. |
| Do you receive payment from patients and return all or a portion of the payment to the hospital? | Select Yes or No to indicate if you receive payment from patients and return all or a portion of the payment to the hospital. |
|
Field |
Description |
|---|---|
|
To add new license, certification, permit or grant, click Add LCPG. Existing LCPG information, if any, is displayed in a table. To edit, in the Licensure, Certification, Permit & Grant table, click the appropriate row. After changing or adding new licenses, certifications, permits or grants, on the License, Certification, Permit and Grant action bar, click Save. Note: Enter the information for all states in which you have credentials. |
|
| Are you adding a Licensure, Certification, Permit, or Grant information? | Select License, Certification, Permit or Grant, depending on which you are adding. Additional fields are displayed for you to enter specific information. |
| License Information Fields | |
| License Number | Provider license number. |
| Licensing Agency | Name of the agency who issued the license. |
| State |
The State that issued the license number. Example: AK |
| Effective Date |
Date when the license became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Expiration Date |
Date on when the license expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Certification Information Fields | |
| Certification # | Provider's certification number. |
| Certifying Agency | Name of the agency who issued the certification number. |
| State |
The State that issued the certification number. Example: AK |
| Effective Date |
Date when the certification became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Expiration Date |
Date when the certification expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Permit Information Fields | |
| Permit # | Provider's permit number. |
| Permit Agency | Name of the agency who issued the permit. |
| State |
The State that issued the permit. Example: AK |
| Effective Date |
Date when the permit became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Expiration Date |
Date when the permit expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Grant Information Fields | |
| Grant # | Provider's grant number. |
| Grant Agency | Name of the agency who issued the grant. |
| State |
The State that issued the grant. Example: AK |
| Effective Date |
Date when the grant became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Expiration Date |
Date when the grant expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
Version as of 6/30/2015.
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