Application instructions

  • ALL fields must be completed unless otherwise directed.
  • Additional instructions are bolded in italics on the application.
  • Submit completed application along with all required documentation.

Application notes

  • For the purposes of this application, "facility" is defined as a hospital; home health agency; skilled nursing facility; ambulatory surgery center; and inpatient, residential, and ambulatory behavior health facility.
  • As required by the facility contract and accrediting agencies, one unique application is required for each facility type and location as listed on page three.
  • Failure to complete this application in its entirety, including submission of required documentation may delay or suspend network participation.
  • The Minnesota Uniform Facility Credentialing Application may be used by other organization. 

Attachments

The processing of your application will be delayed if all required information is not submitted.

    1. Facility identification

    Corporate identification information

    (As reflected on W-9)

    (Application cannot be processed without valid 9 digit TIN)

    (If different than facility address)

    (Application cannot be processed without valid 10-digit NPI)

    Facility information

    Mailing/correspondence address

    2. Medical director or equivalent

    A specific physician medical director or equivalent must clearly be identified and must be licensed in good standing.

    3. Facility type

    One box must be checked based on licensure status. If your provider type is not listed below, do NOT complete this application.

    *For hospitals only*

    Does your facility provide any of the following services?

    4. Facility licensure

      Licensing agency *

      License number *

      Effective date *

      Expiration date *

      5. Medicare status

      6. Accreditation

      If facility is not currently accredited, complete 7. Non-accredited facility section.

      The Facility being credentialed must be listed in the accreditation and a copy of each accreditation is required.

      7. Non-accredited

      Complete this section if facility is not accredited.

      8. Health plan site visit

      Policy attestation

      Please list any other facilities under the same name and/or tax id number as name of facility, specialty and location listed on this application.

      If your facility follows the same policies and procedures as your main facility, Hennepin Health may limit a site visit.

      Attestation:

      I, the undersigned authorized agent, hereby attest and certify that (name of facility, specialty and location) shares the same policies and procedures as: (list all facilities, specialty and locations)

      9. Credentialing program

      10. Insurance coverage

      2. Is this facility covered by professional liability insurance in the minimum amount of $1 million per occurrence and $3 million aggregate? Policy must state it covers all facility employees. (Excess liability/umbrella coverage can count toward the $3 million aggregate amount.) *

      NOTE: Hospitals may be required to have additional insurance cover amounts

        Facility credentialing application languages 

        • Check all languages spoken by facility/agency/program staff fluently enough to treat patients/clients who speak only that language.

        11. Non-Medicare certified home care agency section

        1. Indicate the age range of clients accepted. 

        2. Number of agency employees in each category:

        12. Provider integrity attestation or electronic signature

        I, the undersigned authorized agent, hereby attest and certify that all statements on this entire application are true, accurate and complete to the best of my knowledge. I fully understand that any falsification of information or omissions from this application may be grounds for denial of this application as a participating provider.

         

        I further understand, as an authorized agent of the applicant, that I and the organization have the burden of producing adequate information for the proper evaluation of the organization’s competence, character, and ethics in resolving doubts about such qualifications.

         

        I warrant that I have the authority to sign this application on behalf of the entity for which I am signing in a representative capacity.

        Provider disclosure and attestation for release

        Please provide a written explanation for all YES responses.

        I, the undersigned authorized agent, hereby attest and certify that all statements on this entire application are true, accurate and complete to the best of my knowledge. I fully understand that any falsification of information or omissions from this application may be grounds for denial of this application as a Hennepin Health participating provider.

         

        I further understand, as an authorized agent of the applicant, that I and the organization have the burden of producing adequate information for the proper evaluation of the organization’s competence, character, and ethics in resolving doubts about such qualifications.

         

        I warrant that I have the authority to sign this application on behalf of the entity for which I am signing in a representative capacity.

        If you print your form please fax to 612-677-6264.