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Get Superior HealthPlan SHP 20174169 2019-2024

NetworkDevelopment SuperiorHealthPlan.com Recredentialing Applications Email Credentialing SuperiorHealthPlan.com Fax 1-866-702-4831 Mail Superior HealthPlan s Credentialing Department 5900 E. Ben White Blvd. Non accredited facilities only Return by mail to Superior HealthPlan s Contract Management 7990 Interstate 10 West Suite 300 San Antonio TX 78230 SHP. Austin TX 78741 Please Note A separate Behavioral Health Facility/Ancillary Credentialing Application must be completed for each facility with a unique Federal Tax ID. SHP20174169 1 of 7 Type of Application Initial Credentialing Addition of a new site/service to a current contract Legal Name Parent Company/Health System Name If applicable D/B/A Facility Type Hospital Intensive Family Intervention Adult Living Facility Home Health Agency Federally Qualified Health Center/RHC Other Community Mental Health Center Rehabilitation Center Rehabilitative Behavioral Health Services RBHS Assisted Long-Term Care Facility Outpatient Clinic Substance Use Treatment Facility Identify Levels of Care Offered by Facility If you are already contracted with Superior select only the level of care being added Psychiatric/Mental Health Child Adol Adult Substance Abuse Chemical Dependency Geriatric Inpatient Inpatient Detox Partial IP Rehab IOP Observation Residential ECT I/P Other i.e. SIPP PRTF O/P Medication Assisted Treatment If Detoxification is offered at facility on which unit are services offered Ambulatory Detox Located on Medical Floor/Unit Located on Behavioral Health Floor/Unit 2 of 7 Location 1 Address Other Ambulatory Detox Geri Phone Fax NPI Taxonomy of I/P Beds MH of Medicare I/P Beds If additional locations are needed please make a copy of this page. A copy of your Clinical Laboratory Improvement Amendments CLIA license. If applicable A copy of your Pharmacy license. Not withstanding the foregoing I agree to the following Participation in the credentialing review functions of Superior. Behavioral Health Facility and Ancillary Credentialing Application Please complete the application thoroughly in its entirety. Denial of credentialing status or cause for summary for revocation or suspension of privileges and/or dismissal from the participating network. Include all documentation for multiple facility locations. Medicaid enrollment/certification letter with Medicaid Number. If applicable A copy of your professional and general liability insurance policy with the limits of coverage per occurrence and in aggregate name of liability carrier and insurance effective date and expiration date Month/Day/Year. Accredited and Non accredited facilities Description of Aftercare or Follow up Program* Non-accredited facilities only Organizational Charts including staff to Patient Ratios. Has the corporation an officer or a board member ever been convicted of a felony Yes Facility Responsibility Form I hereby understand that as a prospective/current Superior provider I am solely responsible for ensuring that any licensed practitioners under my employment or working in association with my clinical practice are fully qualified and have all necessary licenses required by all relevant laws to legally perform the assigned functions within my practice.

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