THE BOOK, Cosmetic Surgery Without Fear : Application Form

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Physician selection through credentialing is probably the single most important function that CSC provides. When a physician is interested in becoming part of our referral panel, the process begins with a formal application for participation. This application is sent to an independent credentialing verification organization (CVO) which performs the due diligence necessary to credential the physician in accordance to National Committee for Quality Assurance (NCQA) standards.
To view or print out the physician application as an Adobe Acrobat PDF click here.

Cosmetic Surgery Consultants Provider Application INTERNET REFERRAL NETWORK
For questions about this application, please contact CSC at 770-552-3223

Please fill out the following application completely. This information is part of the CSC Application and Credentialing process for the CSC Internet Referral Network and must be completed in full for network consideration. Failure to do so will delay the verification of your application.

CREDENTIALING / RE-CREDENTIALING
PROVIDER AND ADDRESS INFORMATION

First name:
Middle initial:
Last name:
Home Address:
City:
State:
ZIP:
Professional Designation:	MD
	DO
	Other:
Name(s) of Associates:
Professional Designation:	MD
	DO
	Other:
Group Affiliation or Practice Name:
Primary Office Address:
City:
State:
ZIP:
Phone Number:
Fax Number:
E-mail:
Billing/Payee: (Either Self or Practice)
Name:
Address:
City:
State:
ZIP:
Phone Number:
Fax Number:
E-mail:
If you practice out of more than one office, please include office street address, city, state, zip, phone number, fax number and county.


PROVIDER IDENTIFICATION INFORMATION
Date of Birth:
Social Security Number:
Business Tax ID:

CURRENT MALPRACTICE INSURANCE CARRIER INFORMATION
Insurance Carrier:
Address:
City:
State:
ZIP:
Policy Number:
Effective Date:
Expiration Date:
Coverage Limits:
If group policy, date provider joined group:


PROFESSIONAL STATUS
If you are a MD/DO, are you certified by an ABMS member board?
Y	N

If not ABMs certified, are you certified by the nationally recognized professional certified board in your discipline?
Y	N
Board Name:
Certificate Number:
Original Date of Certification:
Expiration Date:
Date of Re-Certification (if applicable):
Are you Board Eligible?	Y N
Have you taken the Board Certification Examination?
	Y N
Exam Date:
If no, when are you planning on taking the boards?


What is your advertised practice specialty?

PROFESSIONAL EDUCATION AND TRAINING
Professional School:
Street Address of Institution:
City:
State:
ZIP:
Degree:
Graduation Date:
Internship Facility:
Start Date:
End Date:
Residency Facility (list more than one, if applicable):
Start Date:
End Date:
Fellowship Facility:
Start Date:
End Date:

CURRENT HOSPITAL AFFILIATIONS
Please list all hospital affiliations, and locations where you currently perform surgery.
Primary Facility Hospital Name:
Street Address of Hospital:
City:
State:
ZIP:
Department:
Type (Full, Courtesy, etc.):
Additional Facility Hospital Name:
Street Address of Hospital:
City:
State:
ZIP:
Department:
Type (Full, Courtesy, etc.):
Additional Facility Hospital Name:
Street Address of Hospital:
City:
State:
ZIP:
Department:
Type (Full, Courtesy, etc.):

LICENSE AND REGISTRATIONS
Primary License State and License Number (include copy of license):
Primary DEA Number:
ECFMG Number, if IMG:
Effective Date:
Expiration Date:
UPIN Number:
Medicare Provider Number:
Effective Date:
Expiration Date:
CDS State and Number:
Effective Date:
Expiration Date:
Federal TIN Number:

PROVIDER QUESTIONNAIRE
If you answer yes to any of the following questions, please give details.
1. Has any government agency ever investigated, suspended, stayed an action, placed on probation, revoked, placed a condition or conditions, limit or limitations upon, or taken any other action of any kind against any medical or professional license, certification or registration, including but not limited to a license to practice, DEA certification and CDs registration, that you currently or have ever held?
Y N
2. Has any government agency ever denied your application for any medical or other professional license, certification or registration, including but not limited to DEA certification and CDs registration?
Y N
3. Have your privileges at any hospital ever been suspended, diminished, revoked, not renewed, or subject to any restriction, limitation or condition, including but not limited to any requirement for suspension, training, or monitoring of your practice or physical condition?
Y N
4. Have you ever voluntarily withdrawn your privileges, permanently or temporarily, or agreed to accept a leave of absence from any hospital, HMO, group practice, provider network, facility or any other health care organization in order to avoid or delay a quality of care review, peer review, or disciplinary action?
Y N
5. Have you ever been expelled or suspended from receiving payment under the Medicare or Medicaid program?
Y N
6. Have you ever defaulted on a student loan?
Y N
7. ave you ever had any matter referred to a medical licensing authority, peer review, disciplinary, or credentialing, board of a hospital, HMO, group practice, provider network, facility or any other health care organization?
Y N
8. Have you ever been denied membership or renewal thereof, or been subject to disciplinary action by any professional organization?
Y N
9. Have you ever been denied membership or renewal thereof, by any hospital, health maintenance organization, group practice, provider network, facility, or any other health care organization?
Y N
10. Have you ever been arrested, indicted, convicted, or pled guilty to a criminal offense?
Y N
11. Does your use of chemical substance(s), including alcohol, in any way impair your ability to practice medicine with reasonable skill and safety?
Y N
12. Are you currently engaged in the illegal use of controlled dangerous substances?
Y N
13. Are you currently participating in a supervised rehabilitation program or professional assistance program which monitors you in order to assure that you are not abusing or illegally using alcohol or other controlled dangerous substances?
Y N
14. Have you ever been diagnosed as having or have you ever been tested for pedophilia, exhibitionism, or voyeurism?
Y N
15. Do you have a medical condition which in any way impairs or limits your ability to practice medicine with reasonable skill and safety
Y N
(If answered �Yes,� to question 15, then answer Questions 15a and 15b - If answered �No,� skip questions 15a and 15b.)
15a. Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the field of practice, the setting or the manner in which you have chosen to practice?
Y N
15b. Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing treatment (with or without medications) or participate in a monitoring program?
Y N

PROFESSIONAL LIABILITY HISTORY AND COVERAGE
Please email or mail us a current certificate of coverage. Please include information on all cases, even if you may consider the matter insignificant.
1. Has any judgment ever been entered against you in a professional liability case? If yes, please provide dates, circumstances and outcome.
Y N
2. Have you ever been involved in a professional liability case that has been settled in favor of an adverse party? If yes, please provide dates, circumstances and outcome.
Y N
3. Is any professional liability case now pending against you? If yes, please provide dates, circumstances and outcome.
Y N
4. Have you ever been denied malpractice insurance coverage? If yes, please provide an explanation.
Y N

IMPORTANT NOTE: Your failure to provide all information requested in this section of the application or in any other section may result in the denial of your application or your dismissal from Cosmetic Surgery Consultants of Georgia, LLC Internet Referral Network.

PRACTICE INFORMATION
Please fill out the following section completely. This information is part of the CSC Application and Credentialing process and must be completed in full for network consideration. Failure to do so will delay the verification of your application.
E-mail:
Web-site:
PROCEDURE STATISTICS
1. Please check the procedures performed by you and include the average yearly frequency for each procedure. If you do not have exact statistics, please estimate. Place a checkmark in the box next to each procedure in which you have a special interest, advanced training, utilize a new technique, or have higher frequency rates. Should the listing of additional procedures or your comments require additional space, please enter those in the comment box.

	Procedure	Number performed per Year
	Abdominoplasty
	Blepharoplasty
	Breast Surgery
	Augmentation
	Mastopexy
	Reduction
	Reconstruction
	Gynecomastia
	Cheek Implants
	Chemical Peels
	Chin Implants
	Collagen
	Fat Transfer
	Gore-tex, Soft Form, or Other Implant Materials
	Botox
	Otoplasty
	Cosmetic Dentistry
	Cosmetic Tattooing
	Dermabrasion
	Earlobe Repair/Reduction
	Rhytidectomy
	Forehead/Brow Lift
	Hair Removal
	Hair Transplantation
	Hair Restoration
	Scalp Reduction
	Laser Skin Resurfacing
	Lip Augmentation/Reduction
	Body Liposuction
	Scar Revision
	Rhinoplasty
	Sclerotherapy
	Removal of:
	Blood Vessels/Freckles/Sun Spots
	Birthmarks/Port Wine Stains
	Tattoos
	Other


2. What is the average number of consultations you and your staff conduct on a yearly basis?

3. What is the percentage conversion to surgery?
	%
4. What percentage of those with whom you consult do you believe are not truly committed to having surgery in the near future, but perhaps are merely gathering information and/or shopping prices?
	%
5. What percentage of your patient base has more than one procedure (multiple) performed at one time?
	%
6. What percentage of patients do you reject for surgery?
	%
For what reasons: (Check all that apply)
	Too young
	Poor physical condition
	Unrealistic expectations
	Non-compliance
	Other (explain)

7. Do you normally charge a consultation fee?
	Y N
If yes, what is the fee?
8. What percentage of surgeries performed by you is purely reconstructive, versus cosmetic?
	%
9. Do you have surgical experience with different ethnic groups?
	Y N
10. If yes to the above question, please check the ethnic group(s) and list the primary procedure(s) you performed:
Asian
African-American
Other
11. What percentage of your patient base returns for additional services?
	%
Over what period of time?
(6 months, 1 year, two years, three to five years, other)
12. Please provide statistics (using numbers or percentages) on the age/sex mix of your patient base over the last year. Please estimate if exact figures are not available.

Age	Male	Female
0-5
6-12
13-20
21-35
36-55
56-65
65+


PATIENT SERVICES
1. Do you employ a patient advocate/consultant who assists patients with information in preparation for surgery?
	Y N
2. Do you employ a licensed esthetician or skin care specialist?
	Y N
3. Do you have overnight/extended stay accommodations?
	Y N
If not, do you make arrangements for patients?	Y N
Please describe your accommodations or how/where you arrange:

4. What other services do you offer, make available, or refer patients to? Please describe:


5. What are your after hours and "on call" arrangements?

6. Do you send any post-operative gifts to your patients?
	Y N
If yes, what do you send?
7. Please list any languages other than English in which you are fluent:


MARKETING
1. What kind of marketing, advertising or public relations, if any, are you currently doing, or have engaged in over the past year? Please list: i.e., yellow pages ad, direct mail, television, radio, print ads (magazine, newspaper), seminars, infomercials, community service, etc.

2. What approximate costs have you incurred in connection with the marketing of your services over the past year? Please list by type of advertising.

Advertising	Cost

3. What return have you gotten for your advertising? (Has it resulted in actual patients, or just "getting your name out there?") Please explain:

4. Do you believe that your advertising has been as successful as you hoped?
	Y N

MANAGED CARE/INSURANCE
1. With which managed care organizations, if any, are you currently contracted? (HMOs and PPOs) Please list:

2. Does your office routinely handle/file for insurance coverage and predetermination in reconstructive cases?
	Y N
3. Do you accept assignment of insurance?
	Y N

FINANCING
1. Do you offer patient financing (other than Visa, MasterCard, Amex, etc.) at your office?
	Y N
2. What companies do you use? Please list:

3. What percentage of your patients finance all or part of the their surgery?
	%
4. What percentage of patients with whom you have consulted do you believe decided against surgery because of the cost?
	%
5. What percentage of surgery patients (in general) do you believe make a decision based primarily on cost?
	%

COMPUTER IMAGING
1. Do you currently offer video imaging for your patients?
	Y N
2. If you do not offer imaging, what are your reasons, i.e., price, not a useful tool, do not wish to hire personnel, concern over unrealistic patient expectations, etc.? Please explain:

3. If you do offer imaging, who is trained at your facility to use the software? Is anyone specifically assigned to imaging, i.e., the doctor, nurse, other staff members, etc.? Please explain:


COMMUNITY SERVICE
1. Are you currently involved in community service activities, or do you provide services to the economically, socially or physically disadvantaged? Please detail:


SURGICAL LOCATION AND SCHEDULING
1. Do you have your own Surgical Suite / Operating Room where you perform cosmetic surgery?
	Y N 0
2. If yes, please complete the following information:
Name of facility:
City:
State:
ZIP:
Please list certifications
State:	Y N
License #:
Date of certification:
AAAHC/AAAAHC/JCAHO:	Y N
Date of certification:
Re-certification date:
Other (please list, including certification date and re-certification date, if applicable)

Supervision by M.D. Anesthesiologist?	Y N
Is a CRNA present during procedures?	Y N
Explain your Emergency Protocol for transition to a hospital setting

Is the Emergency Protocol updated at least every 2 years?
	Y N
If your Surgical Suite / Operating Room is not currently accredited by any of the above accrediting bodies, are you in the process of review for certification?
	Y N
Scheduled review date:
Are you ALCS certified?	Y N
If yes, what is your expiration date?
2. What is your cancellation and rescheduling policy? Please state:

3. Is a deposit collected when your patient has reserved a surgical date?
	Y N
4. If yes, what amount or percentage?

5. Do you have a surgical scheduling coordinator or office manager who handles scheduling?
	Y N
Name
Title
Phone
E-mail
Other Office Contacts
Name
Title
Phone
Name
Title
Phone

PROFESSIONAL ASSOCIATIONS, SOCIETIES, AND AFFILIATIONS
1. Please list:


FEE SCHEDULE
Please list your current fee schedule for specific procedures so that we may provide it to prospective clients. Please advise us promptly of any changes.

Own surgical facility
Surgical Center/Hospital

CSC will be providing a fee estimate of surgical procedures and anesthesia/facility costs for CSC clients. Please assist us by offering the simplest way in which to estimate your facility/anesthesia charges.
If your anesthesia charges are separate, please indicate below, in the space provided, the unit cost for anesthesia and approximate time required for each procedure or estimate anesthesia charges by procedure. If the facility charges vary by procedure, please indicate in the space provided below. If the facility and/or charges do not vary by procedure, what is the standard facility charge?

	Required	Optional	Optional
Procedure	Surgical Fee	Facility Fee	Anesthesia Fee
Abdominoplasty
Blepharoplasty
Breast Surgery
Augmentation
Mastopexy
Reduction
Reconstruction
Gynecomastia
Cheek Implants
Chemical Peels
Chin Implants
Collagen
Fat Transfer
Gore-tex, Soft Form, or Other Implant Materials
Botox
Otoplasty
Cosmetic Dentistry
Cosmetic Tattooing
Dermabrasion
Earlobe Repair/Reduction
Rhytidectomy
Forehead/Brow Lift
Hair Removal
Hair Transplantation
Hair Restoration
Scalp Reduction
Laser Skin Resurfacing
Lip Augmentation/Reduction
Body Liposuction
Scar Revision
Rhinoplasty
Sclerotherapy
Removal of:
Blood Vessels/Freckles/Sun Spots
Birthmarks/Port Wine Stains
Tattoos
Other

CSC INTERNET PROGRAM

CSC will process the Provider�s application upon receipt of Provider credentialing fee. Upon meeting CSC credentialing criteria, the Provider will be notified of their acceptance in the CSC Internet Referral Program. The credentialing fee is nonrefundable.

CSC will waive the first year membership fee. CSC will invoice the standard membership fee prior to the commencement of the second year. Should the Provider elect not to participate in the program prior to commencement of the second year, there will be no membership fee obligation.

Either party may terminate the provider�s participation in the CSC Internet Referral Program, with or without cause. Should CSC terminate, the provider will be entitled to a refund of the membership fee on a pro-rata basis. Should the Provider terminate, prepaid membership fees are forfeited and there will be no refund.

By becoming a participant in the CSC Internet Referral Network Program, the Provider agrees to adhere to CSC policies and guidelines, which may be adopted from time to time.

Participation in the Internet Referral Network automatically offers eligibility for participation in other CSC programs.

PROVIDER STATEMENT

All information submitted by me in this application is complete, true and correct to the best of my knowledge and belief. I understand that if any of this information is subsequently found to be false, misleading or incomplete, it could result in denial of this application or termination of my participation in the Cosmetic Surgery Consultants Internet Referral Network, as well as any other Cosmetic Surgery Consultants programs in which I participate (hereafter collectively referred to as �CSC�).

I understand and agree that I have the responsibility for producing adequate information for proper evaluation of my qualifications and for resolving any doubts about such qualifications. I also agree to provide information on an ongoing basis as requested and in accordance with any specific future request, which is relevant to a CSC evaluation of my application, credentials or qualifications, and that this statement in its entirety shall also apply then.

I hereby authorize and consent to CSC�s acquisition and verification/credentialing of information from hospitals, medical staff and any other person(s) or organization(s), as long as such acquisition and verification/credentialing is done in good faith and without malice in connection with CSC�s evaluation of my application, credentials and qualifications and for periodic re-credentialing.

I hereby release from liability CSC, its directors, managers, officers, employees, agents or designees, and any and all persons or organizations who provide information to CSC, its directors, managers, officers, employees, agents or designees, for any and all actions taken in good faith and without malice in connection with CSC�s review of my application, credentials, and qualifications and periodic re-credentialing or other activities authorized under this provider statement.

I hereby authorize and consent to the use of my social security number and birth date by CSC, its directors, managers, officers, employees, agents or designees, and any and all persons or organizations who provide information to CSC, its directors, managers, officers, employees agents or designees, in good faith and without malice in connection with CSC�s evaluation of my application, credentials and qualifications, and for periodic re-credentialing.

I hereby authorize release of my malpractice history from my insurance carrier and release of any and all information concerning me from Utilization Review Organizations or Peer Review Organizations.

I hereby hold the sources of such information harmless for release of this information.

I warrant, represent, and attest that to the best of my knowledge the above questions have been answered correctly.

Signature of Provider Applicant	Please print out this form, sign and fax it to: Cosmetic Surgery Consultants Fax: 770-552-9054
Date

CHECKLIST

Thank you for completing your application. This application is the cornerstone of the credentialing process and must be completed in full for network consideration. Be sure to send copies of the items requested below in order to avoid delays.

Copy of Curriculum Vitae (Resume)
Copy of State Medical License
Copy of DEA/CDS
Copy of Medical School Certificate
Copy of ECFMG (where applicable)
Copy of Malpractice insurance declaration page
Detailed malpractice history, including dates and outcomes of each incident
Copy of office liability declaration page
Fee Schedule (the one provided or your own format)
Copies of all written materials given to patient as part of the patient education process, for both pre- and postoperative instructions
Two (2) Professional References (colleagues) - Names and contact information
Two (2) Patient References - Names and contact information (for CSC Staff only) Select patients who would be willing to be interviewed by CSC about their preoperative, surgical and postoperative experience with you/your office.
6-8 �Before and After� Photographs indicating the various procedures you perform. Please supply photos in a 4�x6� size, or provide slides from which we can produce photographs. CSC will cover the cost of reproducing the photographs.

Photographs will be used in the credentialing process and to show CSC clients and potential patients the outcomes of your surgical cases. The photos may also be used on our website and on your personal web page provided by CSC. Supply only those photographs for which you have a signed patient photo release.
Send check for $195 made payable to �Cosmetic Surgery Consultants� OR
Click "Continue" on the next page to charge by credit card.
We must receive a print out, signature and the above list of copies before we can add your name into our database.

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