I hereby apply for privileges to participate with the Empire State Dental IPA Network as requested in this application, and I am willing to make myself available for interviews in regard to said application.
I acknowledge and agree that:
(a) Privileges to participate as a provider with the Empire State Dental IPA, LLC is not a right; and
(b) By applying for privileges with the Empire State Dental IPA, LLC, I am agreeing to comply with the terms and conditions of the Participation Agreement (“Agreement”), whether signed by me or not, pursuant to which I am rendering services to Empire State Dental IPA, LLC Payors’ Members either as a direct contractor, subcontractor, independent contractor, or covering provider.
As an applicant, I agree to produce adequate information for proper evaluation of my qualifications. I also agree to update the Network with current information regarding all questions contained in this application and/or information obtained through the credentialing process as such information becomes available, and any additional information as requested by the Empire State Dental IPA, LLC or its authorized representatives.
Failure to produce such information will prevent my application from being evaluated and acted upon, and may affect any existing privileges I have with the Empire State Dental IPA, LLC.
Information given in, or attached to this application, information obtained from the AMA/ABMS, and/or any subsequent information reviewed and approved by me to be included in the Empire State Dental IPA, LLC and Payor directory(ies)—which may be distributed in any format or media—is accurate and complete to the best of my knowledge.
As a condition to making this application, any misrepresentation or misstatement in, or omission from it, whether intentional or not, shall constitute cause for automatic and immediate rejection of this application, resulting in denial of request for participation. In the event that participation has been granted prior to the discovery of such misrepresentation, misstatement, or omission, such discovery may result in immediate termination of participation.
For the purpose of obtaining and maintaining credentialing or privileges with the Plan, I agree to hold harmless the Empire State Dental IPA, LLC, its authorized representatives, and any third parties from any and all liability for any acts performed in good faith and without malice relating to any communications or disclosures of any kind involving me, which are performed and which are otherwise privileged or confidential information.
Such information may relate to, but is not limited to, information sharing on my professional qualifications, credentials, clinical competence, and any other matter which might directly or indirectly impact or reflect on my competence, on patient care, or on the orderly operation of a health care facility on an ongoing basis.
It is understood that confidential information obtained by the Empire State Dental IPA, LLC will be shared with the Plan, members of the IPA, the IPA’s agents, and any commercial or government payors it is negotiating or contracting with. It shall remain confidential to the fullest extent permitted by law, regardless of whether my membership and privileges are approved or subsequently terminated, except as otherwise provided herein or in the separate provider participation agreement under which I will provide services to Members.
The term “Empire State Dental IPA, LLC and its authorized representatives” means the corporation(s) with which I have applied for participation, and any of the following individuals who may have any responsibility for obtaining or evaluating my credentials, or acting upon my application: the members of the Empire State Dental IPA, LLC Board and their appointed representatives, the President or his designees, other Empire State Dental IPA, LLC employees, consultants to the Empire State Dental IPA, LLC, delegated credentialing entities, the Empire State Dental IPA, LLC attorney and his/her partners, associates, or designees.
The term “third parties” means all individuals, including appointees to the Empire State Dental IPA, LLC Payors’ (medical insurance carriers) medical staffs, hospitals, other physicians or health practitioners, nurses, government agencies, organizations, professional liability insurance carriers, associations, partnerships, and corporations—whether health care facilities or not—from whom information has been requested by the Empire State Dental IPA, LLC or its authorized representatives, or who have requested such information from the Empire State Dental IPA, LLC and its authorized representatives.
