I authorize Wilmington Mental Health, its affiliates, employees, and agents, to obtain information regarding my experience and qualifications I hereby authorize and give my consent to Wilmington Mental Health to release to any entity contracting with Wilmington Mental Health, including manage care networks, EAPs or healthcare organizations, any and all information that may be relevant to Wilmington Mental Health's credentialing or recredentialing process.
I hereby hold harmless Wilmington Mental Health and any and all entities providing information to Wilmington Mental Health from any liability connected with or arising from the release of such information. Furthermore, I hold harmless Wilmington Mental Health from any liability arising from its evaluation of this application and its credentialing procedures. I further agree that in the event that there are any changes with respect to the information I provided in this application, I shall immediately notify Wilmington Mental Health of such changes.
I hereby represent and warrant that this application has been completed in good faith and that all information is true, accurate and complete.
Provider Rights
• The right to review information obtained during credentialing process subject to applicable laws and excluding any peer review information.
• The right to request the status of their application at any time. This request may be made by contacting our Office Manager verbally or in writing. Status is defined as one of the following: (a) incomplete application (b) primary source verification, meaning the application information is currently being verified or (c) pending review, meaning the verification of information is completed but the file has not yet been reviewed by the insurance Committee.
• The right to correct erroneous information obtained during the credentialing or re-credentialing process. The provider must respond, in writing, to Provider Relations (i.e., Insurance Company) within 30 days. The provider must explain the discrepancy, may correct any erroneous information, and may provide any proof that is available.
• The right to appeal a denial decision. The provider must respond in writing, to Provider Relations within 30 days of the decision date. The provider should include any additional information available.
The following documentation will be required as part of the credentialing application (as applicable):
o Professional License
o Education and Professional Work History
• Please note: If you have had any gap in employment that was longer than 90 days, please add this information with the month and year (to and from) with brief explanation.
o Certificates and Diplomas
o Board certification (optional)
o Updated Resume or Curriculum Vitae (CV)
• Must show Wilmington Mental Health as present employer
o National Provider Identifier (NPI) Number
o Government-issued picture identification (Driver’s License or Passport)
o Social Security Number
o Drug Enforcement Administration Registration Number (DEA)
o Hospital affiliation
o Life support training (CPR, ACLS, PALS according to the requested privileges)
o Proof of Malpractice Coverage
Please Note: It is your responsibility to ensure that all information reported on this application is factual.