Provider Application – Doula Provider

Instructions:

Please complete the below application and provide comments as appropriate.

All information is confidential.

Required fields are marked with an asterisk (*)

The information entered on this page can be saved to allow for completion at a later date. Incomplete requests will automatically delete from the system after 30 days of inactivity.

Date*

Contact Name*

Contact Title*

Contact Phone Number*

Contact Email Address*

Enter Email Confirm Email

Are you interested in contracting as an individual Doula or as a Group:*

Are you interested in contracting as an individual Doula or as a Group: *

Individual
Group

Section 1: Provider Information

If Individual – please utilize the below questions for the application:

Provider Name*

Include First Name, Middle Initial, and Last Name

Specialty*

NPI (Type I)*

10 Digit Number

Tax ID*

Address*

Street Address Address Line 2 City State ZIP

Phone Number*

Mailing Address (If different than above)

Street Address Address Line 2 City State ZIP

Website URL

Start with https://

Practitioner is enrolled with Rhode Island Medicaid:*

Practitioner is enrolled with Rhode Island Medicaid: *

Yes
No

Per federal requirements, all providers participating in the Neighborhood network are required to be enrolled with Rhode Island Medicaid. If you are currently not enrolled with Rhode Island Medicaid, please visit the Rhode Island Executive Office of Health and Human Services Provider Enrollment Page for additional information on how to enroll: Rhode Island Medicaid Provider Enrollment Application.

Section 2: Practice/Facility Information

If Group- please utilize the below questions for application:

Practice Facility Name:*

NPI(Type II)*

Tax ID:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Office Phone Number*

Extension:

Mailing Address (If different than above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Website URL

Start with https://

Provider group and its practitioners are enrolled with Rhode Island Medicaid:*

Provider group and its practitioners are enrolled with Rhode Island Medicaid: *

Yes
No

Per federal requirements, all providers participating in the Neighborhood network are required to be enrolled with Rhode Island Medicaid. If you are currently not enrolled with Rhode Island Medicaid, please visit the Rhode Island Executive Office of Health and Human Services Provider Enrollment Page for additional information on how to enroll: Rhode Island Medicaid Provider Enrollment Application.

Please provide the following information for all practitioners providing services.*

Name:	NPI:

Section 3: Other Provider Information

Have you ever been excluded from participating with Medicare/Medicaid*

Have you ever been excluded from participating with Medicare/Medicaid *

Yes
No

Per regulatory requirements any provider who is excluded from participation with Medicaid and/or Medicare is unable to join the network. We encourage you to apply in the future should circumstances change.

If you have any questions please address them in the below section.

Please Attach A Current W-9. W-9 Must have been completed within 6 months of today’s date.*

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

Provider Participation Criteria for Birth Doulas (CD) and Postpartum Doulas (PD)

All Doulas requesting network participation must meet Neighborhood Health Plan of Rhode Island’s (Neighborhood) credentialing criteria as documented below.

1. Provider and its practitioners are certified by the Rhode Island Certification Board (RICB)*

1. Provider and its practitioners are certified by the Rhode Island Certification Board (RICB) *

Yes
No

In order to participate in the Neighborhood network Doula providers are required to be certified by the Rhode Island Certification Board. Based on the information you have provided you are unable to proceed with your application.

Comment

2. Please Attach a Copy of the applicable RICB Certificate. Please include one certification for each practitioner if applying as a group.*

Drop files here or

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

3. Provider maintains professional liability insurance at a minimum amount of One Million Dollars ($1M)*

3. Provider maintains professional liability insurance at a minimum amount of One Million Dollars ($1M) *

Yes
No

Comment

4. Please Attach a Copy of your Liability Insurance Face Sheet*

Drop files here or

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

5. Provider has completed their application with CAQH.*

5. Provider has completed their application with CAQH. *

Yes
No

Comment

CAQH #*

6. Provider is in good standing with state and federal programs.*

6. Provider is in good standing with state and federal programs. *

Yes
No

Comment

As an authorized representative of the practice indicated above, I have reviewed and attest to the best of my knowledge, the information provided on this Questionnaire is accurate and complete.

Name/Title*

Signature*

Signature Date*

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

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