Insurance Credentialing Authorization Attestation Form

I authorize Riccobene Central Services, LLC a North Carolina professional corporation, its affiliate North Carolina professional corporations Riccobene and Associates Family Dentistry et al ("Entity(s)" including, without limitation, its representatives, employees, and/or designated agent(s); the Entity's affiliated entities and their representatives, employees, and/or designated agents; and the Entity's designated professional credentialing enrollment organization (collectively referred to as "Agents"), to complete all or parts of enrollment applications and provider agreements, which includes both oral and written statements, records, and documents, concerning my application for Participation. I agree to allow the Entity and/or its Agent(s) to sign my name on my behalf, provide my signature electronically or otherwise for the sole purpose of insurance credentialing and enrollment.

My authorization includes creating and/or providing login and password access to include but not limited to provider portals, NCTracks Medicaid, American Dental Association and CAQH (Council for Affordable Quality Healthcare) profiles for the purpose of making changes on my behalf to maintain my provider credentials and continue my provider enrollment.

Attestation & Release from Liability I release from all liability and hold harmless Riccobene Central Services, LLC, its affiliate et al ("Entity(s)"), its Agent(s), and any other Riccobene & Associates Family Dentistry designated third party for their acts performed in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of the Entity, its Agent(s), or other third party in connection with the gathering, release and exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release. The Entity or any of its affiliates or agents retains the right to allow access to the application information for purposes of a credentialing or maintenance of licensure.

I understand and agree that this Authorization, Attestation and Release is irrevocable for any period during my employment with Riccobene & Associates Family Dentistry, its affiliate Riccobene Central Services, LLC et al ("Entity") or as a participating provider under the Entity. I agree to execute another form of consent if law or regulation limits the application of this irrevocable authorization.

I agree that information obtained in accordance with the provisions of this Authorization, Attestation and Release is not and will not be a violation of my privacy.

DENTIST FULL NAME

DENTIST SIGNATURE

DATE

Date

Provider Name

NPI

1. Has your license to practice in any jurisdiction ever been limited, restricted, reduced, suspended, voluntarily surrendered, revoked, denied or not renewed; have you ever been reprimanded by a state licensing agency; or are any of these actions pending with respect to your license; are you under investigation by any licensing or regulatory agency?

YesNo

2. Has your professional employment or membership in a professional organization ever been subject to disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed, or voluntarily relinquished during or under threat of termination for any reason?

YesNo

3. Has your Drug Enforcement Agency registration or other controlled substance authorization ever been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily surrendered or limited your registration during or under the threat of an investigation or are any such actions pending?

YesNo

4. Have you ever been sanctioned or suspended by Medicare or Medicaid?

YesNo

5. To your knowledge, have you ever been reported to the National Practitioner Data Bank or the North/South Carolina or Virginia State Board of Dental Examiners?

YesNo

6. Have you ever been convicted of a felony or misdemeanor, or are you under investigation with respect to such conduct?

YesNo

7. Has a professional liability claim been assessed against you in the past five years, or are there any professional liability cases pending against you?

YesNo

8. Has any liability insurance carrier canceled, refused coverage, or rated up because of unusual risk or have any procedures been excluded from your coverage?

YesNo

9. Have you ever practiced without liability coverage?

YesNo

10. Do you currently have any medical, chemical dependency or psychiatric conditions that might adversely affect your ability to practice medicine or surgery or to perform the essential functions of your position?

YesNo

11. Have your Hospital and/or Clinic privileges ever been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily surrendered or limited your privileges during or under the threat of an investigation or are any such actions pending?

YesNo

If you answered "Yes" to any of the below questions, please use the box below to explain. Please note that we will need any documentation as well to submit in with the credentialing paperwork (If we have any additional questions, we will reach out via email/phone)

Provider Signature

Date

RICCOBENE ASSOCIATES

PROFESSIONAL INFORMATION