2017-18 Western Oregon Mental Health Alliance Renewal Document
Participating Provider Agreement (PPA)
Professional Legal First Name *
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Legal Last Name *
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NPI Number *
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Tax Identification Number *
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Professional Degree(s) *
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Professional License Number *
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Licensing State *
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Mailing Address *
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City *
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Home Telephone *
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Email *
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Work Address *
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Work Email *
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Mission: Western Oregon Mental Health Alliance, INC. (WOMHA) is a non-profit organization of licensed mental health practitioners incorporated under the laws of the State of Oregon. WOMHA operates as independent professionals who market ethical professional services and provides public education concerning the necessary confidentiality, integrity and quality of clinical relationships. WOMHA operates regional contracting and referral services and participates in national marketing projects. WOMHA respects and preserves the professional integrity of its members, and the confidentiality of client-therapist relationships. WOMHA is committed to improving programs for delivery of high quality mental and behavioral health services. *
Statement of Mission--please initial below acknowleding you read the above statement
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Collaboration: Members of WOMHA agree to support the Mission of the WOMHA and agree to participate collaboratively with WOMHA. WOMHA is incorporated as a non-profit mutual benefit corporation in the State of Oregon. As such, no interest or dividends will accrue to members of the organization, or to any other parties. All fully enrolled members will be participants in regional, statewide, national and locally advertised Internet referral programs and may participate in contracting activities by separate agreements. *
Benefits and Limitations of Membership--please initial below acknowledging you read the above statement
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Funds: The only funds available to WOMHA are membership enrollment fees and future member dues. These funds are to be used strictly for the purposes of WOMHA development and operation. Membership enrollment fees are non-refundable and non-transferable unless you have credentialing issues that prevent participation. The enrollment fee to join WOMHA consists of a one time initiation fee of $ 1,000 or $600 (if Early Career option) in addition to yearly dues to WOMHA. Yearly membership dues will be determined by the Board of Directors and will be based on an assessment of the operating and administrative costs of operating WOMHA. A member shall not make any misrepresentation to patients concerning the policies of WOMHA or any misrepresentation regarding the provision of mental health services. All applicants for membership shall deliver to WOMHA adequate information for a proper evaluation of competence, training, character, and other qualifications as required in the member credentialing on the WOMHA website. Material misrepresentations or omissions in an application shall be grounds for denial or revocation of membership. The Board of Directors must approve all applicants. *
Membership Fees & Requirements-- please initial below acknowledging you read the above statement.
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Contracting: Enrolled member-owners of WOMHA are eligible to participate in the chapter’s model for group contracting after they complete required education and adopt the practice methods and policies required for contracts participation. A contracted member must comply with the care integration, quality guidelines, electronic records standards, utilization standards, screening and outcomes measures required by participating plans and/or established by WOMHA and participate in, accept the results of and comply with the requirements of the utilization review process as required by the participating professional agreement, the Bylaws and the Rules and Regulations of WOMHA. Failure to do so may result in termination of a member’s rights to participate in contracts. * Please indicate whether you are interested in learning more about contracts participation. *
Contracting--please initial below acknowledging you read the above statement.
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Risks: WOMHA members accept the risks of operating in a competitive business environment, such that neither the success of the entire WOMHA nor the success of any individual member is in any way promised or guaranteed by WOMHA membership. Rather, membership provides opportunity to participate as an independent practitioner building and maintaining your clinical practice. Dues setting and other operational decisions will be determined in keeping with the Policies and Bylaws of WOMHA, to be set forth separately *
Risk Disclosure: please initial below acknowledging you read the above statement.
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Management: Those entering in to Membership in WOMHA are advised that 1. Management of WOMHA is in the hands of a Board of Directors which consists of peer professionals; 2. Membership enrollment fees, dues, will be used for WOMHA development and operations and are not refundable; 3. In the future,the WOMHA Board of Directors may elect to increase or decrease the membership enrollment fee and,if it is decreased,no refunds will be paid; 4. In the future,the elected Board of Directors and/or WOMHA members might vote to increase dues or to levy assessments to be paid by members and members would be bound to abide by a decision to pay such dues or assessments in order to retain their memberships; 5. In the planning and provision of services each WOMHA member will be bound by the ethical principles adopted by the licensing board which regulates his or her profession as well as the laws of the State of Oregon. *
Management: please initial below acknowledging you read the above statement.
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Acceptance: By signing this Application and Disclosure Statement I agree to support WOMHA's mission, and to accept the benefits and limitations set forth herein. I understand that I must submit the following for review and acceptance by the WOMHA Membership process to complete my WOMHA membership enrollment: 1). Proof of my current license as an Oregon Mental Health Professional which is entered and linked on my WOMHA electronic page; 2). Provide proof of my current malpractice insurance coverage entered and attested on my WOMHA electronic page; 3). Pay initial membership enrollment fee of $1000, as one payment or 4 payments of $260 each and dues of $400. These dues will be paid on-line at WOMHA's website. I will provide my proof of licensure and malpractice coverage. *
Application & Disclosure Statement--please initial below acknowledging you read the above statement.
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List Serve Permission - I would like to continue to participate in the WOMHA e-mail list-serve. *
PRACTICE REVIEW 1. Do you have any limitation or disability that requires special consideration or accommodation in order to practice? (e.g. chronic illness, physical impairment, etc.) *
We appreciate that information provided within this section may be of a sensitive nature. WOMHA will treat all information provided here as confidential to the fullest extent allowable by law. The WOMHA representatives reviewing your responses will hold them confidential and will use your responses solely for safeguarding the interests of WOMHA
2. Are you or have you been subject to discipline by a professional organization? *
3. Are you or have you been subject to suspension, limitation or revocation of hospital practice? *
4. Are you or have you been subject to sanction from Medicare, Medicaid, Workers' Compensation or CHAMPUS? *
5. Are you or have you been subject to sanction from any HMO, PPO, or other third party payer? *
6. Are you or have you been subject to any civil action brought against you concerning your professional practice? *
7. Are you or have you been subject to professional liability insurance cancellation? *
8. Are you or have you been subject to state license investigation, restriction, suspension, or revocation? *
9. Are you or have you been subject to arrest for or conviction of a felony? *
10. Are you or have you been subject to DEA license investigation, restriction, suspension, or revocation? *
11. Are there now any complaints, charges or investigations pending against you with any licensing boards or professional ethics bodies? *
12. Do you currently have any reason to believe that a civil action relating to your professional practice may be brought against you in the future? *
13. Have you ever engaged in a sexual relationship with a current or former client? *
14. Have you ever engaged in a sexual relationship with any person having a direct relationship to a current or former client? *
If you have answered yes to any of the 14 questions which form the PRACTICE REVIEW above. Please explain your answer in the space provided below. As noted earlier, all answers will be kept confidential by the professionals who participate in WOMHA's membership application review process. *
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CERTIFICATION: I, the undersigned, hereby attest that the information given in or electronically part of my application is accurate and complete. I specifically allow authorized representatives of WOMHA to consult with any third party that may have information bearing on the subject matter addressed by this application and to inspect or obtain any reports, records, recommendations, or other documents or disclosures of third parties that may be material to the questions in this application. I also specifically authorize any third parties to release information to authorized representatives of WOMHA upon request. I hereby release authorized representatives of WOMHA, and any third parties, from any liability for any reports, records, recommendations, or other documents or disclosures involving me that are made, requested, or received by WOMHA's authorized representatives to, from, or by any third parties, including otherwise privileged or confidential information, made or given in good faith and relating to the subject matter addressed by this application. *
Please enter your initials to verify that you have read and understood this certification statement.
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ACCOMMODATION: WOMHA does not discriminate on the basis of race, national origin, age, gender, disability, religious affiliation or sexual orientation We recognize the Americans with Disabilities Act. *
If you require accommodation under that law, please initial below.
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HOLD HARMLESS: With regard to referrals received through WOMHA’s print directory, contracting, referral or web listing services: I shall assume the risk of liability for, and shall indemnify, defend, protect and hold harmless WOMHA, and its affiliated chapters, hereafter referred to as the "Service" and the officers, agents and employees of those entities from and against any and all claims, damages, suits, judgments, liabilities, losses, court costs and expenses, including attorney's fees, for all injury, sickness, disease, or damages arising out of, or in the course of my accepting a referral or making a referral to another member by me or any of my agents or employees and for any acts or omissions in my treating or not treating patients referred to me by this Service. I also agree to keep my malpractice insurance in force until the statutes of limitations expire for the filing of malpractice claims associated with any person referred by this Service. *
Please enter your initials to verify that you have read and understood this hold harmless statement.
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PROFESSIONAL MALPRACTICE INSURANCE: Without limiting the scope or the extent of the protection afforded the Service by the liabilities I have assumed in the preceding HOLD HARMLESS statement, I shall maintain in force for the life of this agreement, liability insurance to cover the liabilities I assumed in the preceding paragraph. I shall continue such coverage following termination of this agreement so as to afford protection to the Service. I shall also promptly notify the Service of any cancellation, reduction or other material change in the amount or scope of any coverage(s) required in this application. *
Please enter your initials to verify that you have read and understood this professional malpractice insurance statement.
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MEMBER AGREEMENT: I agree that as a member of this organization that I will abide by all federal, state and local laws pertaining to practice in my area and to provide ethical and continuous care of all people referred to me through the Service. I agree to inform the directors of WOMHA in the event of any malpractice lawsuit filed against me or if there are any changes in my status as attested in my Application. I understand that membership fees will be utilized to cover the costs of employee's or contractors wages, computer software, hardware, advertising, accounting, printing and other administrative expenses. I understand that WOMHA reserves the absolute right to remove any member from the referral list and/or cease referrals in the event of: loss or suspension of their license, suspension or loss of DEA number, conviction of a misdemeanor or felony involving moral turpitude, disciplinary action taken by a professional society or by the suspension or loss of staff privileges at a hospital or report made by the hospital to the Board of Medical Quality Assurance, or any mental or physical incapacity rendering a member unable to practice ethically, any failure to adhere to the membership requirements or a member's failure to meet the standards of WOMHA, or omissions or false statements contained in my Application, or any breach of this contract, any failure to maintain insurance, or failure to practice in good faith and maintain a reasonable standard of care. *
Please enter your initials to verify that you have read and understood this member agreement.
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Any Information entered by you in written or electronic enrollment statements that subsequently is found to be false could result in refusal to enter into a contract with you or termination of any contract with you. I have read and understand the terms and conditions of WOMHA's Professional membership. I further understand that until WOMHA has received, reviewed and approved my Application to become a Professional Member of WOMHA and I have executed a Participating Provider Agreement, my status is that of an applicant and not as a Member of WOMHA. Your electronic signature is required to complete this application. *
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