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This form is for practitioners providing care in hospital or free-standing facility settings for Regence BlueCross BlueShield of Utah members. It requires information on qualifications and essential
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How to fill out hospital and -standing facility
How to fill out Hospital and Free-Standing Facility Based Practitioner Information Form
01
Obtain the Hospital and Free-Standing Facility Based Practitioner Information Form from the appropriate source.
02
Fill in the practitioner's full name in the designated section.
03
Provide the practitioner's medical license number and issuing state.
04
Include the address of the hospital or facility where the practitioner is based.
05
List the contact information, including phone number and email address.
06
Indicate the type of practice (such as surgery, primary care, etc.) in the specified area.
07
Fill out any additional required fields, such as specialties or certifications.
08
Review the completed form for accuracy and completeness.
09
Sign and date the form as required.
10
Submit the form to the relevant department or entity as instructed.
Who needs Hospital and Free-Standing Facility Based Practitioner Information Form?
01
Healthcare practitioners working in hospitals or free-standing facilities.
02
Administrative personnel responsible for maintaining practitioner records.
03
Insurance companies requiring verification of practitioner details.
04
Regulatory bodies that oversee healthcare facilities and practitioners.
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People Also Ask about
What is considered a free-standing facility?
What's a freestanding facility? Freestanding (or stand-alone) facilities provide medical services under the direction of a physician, but they're not part of a hospital.
What is an example of a freestanding facility?
Physically separate facilities on the campus of a Hospital are considered freestanding unless they are integrated with, or a department of, the Hospital. Examples of Freestanding Facilities include, but are not limited to, Free-Standing Cardiac Care Facilities and Free-Standing Residential Treatment Centers.
What is a free standing medical facility?
Freestanding (or stand-alone) facilities provide medical services under the direction of a physician, but they're not part of a hospital.
What is considered a free-standing building?
Definition of freestanding building a structure that is not attached to another structure. Example: The Big Eats Grocery company always places its stores in freestanding buildings rather than locate in attached buildings of shopping centers, even if the store could be the anchor tenant.
What is an example of a free standing facility?
Physically separate facilities on the campus of a Hospital are considered freestanding unless they are integrated with, or a department of, the Hospital. Examples of Freestanding Facilities include, but are not limited to, Free-Standing Cardiac Care Facilities and Free-Standing Residential Treatment Centers.
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What is Hospital and Free-Standing Facility Based Practitioner Information Form?
The Hospital and Free-Standing Facility Based Practitioner Information Form is a document used to collect and report detailed information about healthcare practitioners who provide services in hospitals and free-standing facilities.
Who is required to file Hospital and Free-Standing Facility Based Practitioner Information Form?
Healthcare practitioners who provide services in hospitals and free-standing facilities are required to file this form, including but not limited to physicians, surgeons, and other medical providers.
How to fill out Hospital and Free-Standing Facility Based Practitioner Information Form?
To fill out the form, practitioners should provide accurate personal identification information, details about their medical qualifications, and any relevant affiliations with hospitals or facilities, following the instructions provided in the form guidelines.
What is the purpose of Hospital and Free-Standing Facility Based Practitioner Information Form?
The purpose of the form is to ensure transparency and accountability in the healthcare system by collecting essential data on practitioners to facilitate regulatory compliance and improve patient care.
What information must be reported on Hospital and Free-Standing Facility Based Practitioner Information Form?
The form must report information such as the practitioner's name, medical specialty, licensing details, employment history, and any disciplinary actions or malpractice claims.
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