Credentialing Attestation - Cedar Family Centers

Cedar Family Center Practice Standards

Please fill in the below form. All fields are required and confidential.
The Information entered on this page can be saved to allow for completion at a later date. Incomplete requests will be automatically deleted from the system after 30 days of inactivity.

Facilities requesting network participating as a Cedar Family Center provider must provide the following information and attach applicable documentation and submit to Neighborhood Health Plan of Rhode Island (Neighborhood) for review. Provider must attest to meeting practice standards outlined on the State of Rhode Island’s Executive Office of Health and Human Services Practice Standards for Cedar Family Centers issued January 1, 2016. The Practice Standards for Cedar Family Centers can be found above. This form must be completed and signed by an authorized individual. Providers must re-attest to meeting the Service Practice Standards every 3 years thereafter for recredentialing to continue as a network provider. Neighborhood retains the right to conduct a quality onsite assessment prior to approving the facility for services, for recredentialing or in response to a complaint received from a member pertaining to quality of the environment or service.

A copy of provider certification and liability coverage must be included with the signed attestation.

Upload Certification and Liability coverage document*

Accepted file types: pdf, Max. file size: 10 MB.

Attach pdf

Provider Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax*

Facility NPI*

10 digits

Facility Contact Name*

First Last

Affirmation of Facility

Please attest to the below information by providing your initials in the box provided below.

Provider complies with State of Rhode Island EOHHS Practice Standards*

Please Initial

Family care plan is reviewed and signed by an independently licensed clinician*

Please Initial

Criminal background check is conducted for all personnel employed by the provider*

Please Initial

Provider conducts ongoing screening and monitoring to ensure all personnel employed and vendors the provider contracts with are not excluded from Medicare /and/or Medicaid program*

Please Initial

Any entity or agency providing service in collaboration with the provider must be a Neighborhood provider (credentialed/contracted)*

Please Initial

Name of Authorized Individual/Title*

Print Name

Signature of Authorized Individual*

Date*

Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network.

CAPTCHA