Network Participation - Sleep Lab Profile & Application

 

Company Information (RED indicates required field)

Referred By
Company Name DBA
Primary Contact Email
Physical Address City
State Zip
Phone
Federal Tax ID (TIN) License No.
Medicare No. Medicaid No.
We can guarantee an appointment time for any referral if provided with a minimum 4-week lead time

Liability Insurance Information

Liability Insurance Carrier  
Policy Number Expiration Date
Liability Coverage per occurrence ($M)  
Liability Coverage general aggregate ($M) Liability Coverage professional ($M)

Corporate Accreditation & Staff Certification

Accreditation Yrs Accredited Expiration Date Accreditation Yrs Accredited Expiration Date

Certification # of Staff Certification # of Staff

Software Programs

We use the current software programs for PSG testing

Trade References

Company Yrs associated
Contact Telephone
Address City
State Zip

Company Yrs associated
Contact Telephone
Address City
State Zip

Corporate Compliance

Does your organization have a formal quality assurance program?
Does your organization have a formal infection control plan?
Does your organization have policies and procedures for patient grievance and resolution?
Are the credentials, certifications and/or licenses of personnel involved in the care and/or treatment of patients verified by your organization prior to employment or contract?
Are the credentials, certifications and/or licenses of personnel involved in the care and/or treatment of patients re-verified by your organization at least every three years or at expiration?
Are you able to provide / deliver same day urgent services, 24 hours a day / 7 days a week?
Do you run background checks on all personnel (employed / contracted) who enter a patient’s home (if applicable)?

Corporate History

Have you had any Medicare / Medicaid sanctions within the last 10 years?
Has your organization or any member of your staff ever been expelled, excluded, or suspended from any federal program or from service reimbursement under Medicare or Medicaid?
Are there any actions contemplated or pending against this organization by any government agency, professional group, institution, or other entity?
Has your organization’s professional liability coverage ever been restricted, limited, denied or cancelled?
Has any insurance carrier ever made an out-of-court settlement or paid a judgment on a professional liability claim on your organization’s behalf?
At present or during the last five years, has this organization been part of any legal proceedings?
Do you have any litigation pending?
Have there ever been any actions against your organization’s license, accreditation, certifications or permits or the license of any member of your staff, including restrictions, limitations, denial, suspension, revocation or cancellation?
Has your organization or any member of your staff ever been convicted of or pleaded no contest to a felony or other criminal offense, including, without limitation, a criminal offense related to Medicare, Medicaid, or any other federal program?
Has your organization ever lost its accreditation status?

Facility Locations

Number of Locations
Primary or Corporate Address City
State Zip
Phone
Number of Beds Number of Employees
Days of Operation Hours of Operation TO
Primary GOMEDEDGE Admin Contact Email

Facility Address 2 City
State Zip
Phone
Number of Beds Number of Employees
Days of Operation Hours of Operation TO
Primary GOMEDEDGE Admin Contact Email

Facility Address 3 City
State Zip
Phone
Number of Beds Number of Employees
Days of Operation Hours of Operation TO
Primary GOMEDEDGE Admin Contact Email

Facility Address 4 City
State Zip
Phone
Number of Beds Number of Employees
Days of Operation Hours of Operation TO
Primary GOMEDEDGE Admin Contact Email

I hereby attest that all information provided in this or in connection with this application is complete and accurate to the best of my knowledge, and I shall immediately notify The MED Group of any changes thereto. I understand that this application does not entitle me to participate in referral networks. I hereby attest I am approved to complete and submit this information to The MED Group.