| HSD-1 COUNTY/DELIVERY SYSTEM SUMMARY OF PROVIDERS BY SPECIALTY | |||||||
| Date Prepared: | |||||||
| Applies to plan(s): | |||||||
| Specialty | Medicare Provider Breakdown | Total # of Providers | May Providers Serve as PCPs? | Total # of PCPs Accepting New Patients | Total # of PCPs Accepting Only Established Patients | County | |
| Direct w/MAO | Downstream Arrangement | ||||||
| General Practice | |||||||
| Family Practice | |||||||
| Internal Medicine | |||||||
| Mid -Level Practitioners | |||||||
| Obstetrics/Gynecology | |||||||
| Cardiology | |||||||
| Chiropractic | |||||||
| Dermatology | |||||||
| Endocrinology | |||||||
| ENT | |||||||
| Gastroenterology | |||||||
| General Surgery | |||||||
| Geriatrics | |||||||
| Nephrology | |||||||
| Neurology | |||||||
| Oncology | |||||||
| Ophthalmology | |||||||
| Oral Surgery | |||||||
| Orthopedics | |||||||
| Podiatry | |||||||
| Psychiatry | |||||||
| Pulmonology | |||||||
| Radiology | |||||||
| Rheumatology | |||||||
| Urology | |||||||
| Vascular Surgery | |||||||
| TOTALS | |||||||
| HSD-2 PROVIDER LIST - LIST OF PHYSICIANS AND OTHER PRACTITIONERS BY COUNTY | ||||||||||||||||||
| Date Prepared: | ||||||||||||||||||
| Applies to plan(s): | Service Address | |||||||||||||||||
| Name of Physician or Mid-Level Practitioner | Specialty | Contract Type | Street Address | City | State | Zip Code | County | Provider Previously Listed? | Contracted Hospital Where Privileged | May Provider Serve as PCP? | If PCP, Accepts New Patients? | If PCP, Accepts Only Established Patients? | Does MCO Delegate Credentialing? | If Credentialing is Delegated, List Entity | Medical Group Affiliation | Employment Status | ||
| Y or N | Y or N | Y or N | Y or N | Y or N | MGA or DC | |||||||||||||
| HSD-2A - CONTRACTS & SIGNATURE PAGES INDEX | |||||
| (COUNTY) SERVICE AREA EXPANSION | |||||
| PCP / Specialty | Contract Templates | Existing Network | |||
| Template A | Template B | Template C | Template D | ||
| HSD-3 ARRANGEMENTS FOR MEDICARE REQUIRED SERVICES BY COUNTY | |||||||||||||||||||||||||||
| Date Prepared: | |||||||||||||||||||||||||||
| Applies to plan(s): | Location | Acute Inpatient Hospital Care | Diagnostic & Therapeutic Radiology (excluding Mammogram) | DME/ Prosthetic Devices | Home Health Services | Lab Services | Mental Illness - Inpatient Treatment | Mental Illness - Outpatient Treatment | Renal Dialysis - Outpatient | SNF Services | Surgical Services - Outpatient or Ambulatory | Therapy - Outpatient Occupational/Physical | Therapy - Outpatient Speech | ||||||||||||||
| TRANSPLANTS | |||||||||||||||||||||||||||
| Name of Provider | Type of Provider | Street Address | City | State | Zip Code | County Served By Provider | Provider Previously Listed? | Mammography | Heart | Heart and Lung | Intestinal | Kidney | Liver | Lung | Pancreas | ||||||||||||
| Y or N | |||||||||||||||||||||||||||
| HSD-3A - CONTRACTS & SIGNATURE PAGES INDEX, ANCILLARY / HOSPITAL | ||||||||
| Date Prepared: | ||||||||
| Ancillary / Hospital | Tab Name | Existing Network | ||||||
| HSD-4 ARRANGEMENTS FOR ADDITIONAL AND SUPPLEMENTAL BENEFITS BY COUNTY | |||||||||||
| Date Prepared: | |||||||||||
| Applies to plan(s): | Location | Dental Care | Providing Eye Glasses & Contacts | Providing Hearing Aids | Pharmacy Prescription Drugs (outpatient) | Screening - Hearing | Screening - Vision | ||||
| Name of Provider | Street Address | City | State | Zip Code | County Served By Provider | ||||||
| HSD-5 - SIGNATURE AUTHORITY GRID | ||
| PRACTICE NAME | SIGNATURE AUTHORITY | PHYSICIANS |
| File Type | application/vnd.ms-excel |
| File Title | HSD-1 |
| Last Modified By | CMS |
| File Modified | 2006-03-24 |
| File Created | 2001-04-25 |