Hospitals

NOTE: Please print, complete and submit the “CenterPoint Provider Hospital Based Inpatient and Outpatient Psychiatric Services Application” and additional required materials.

If you have recently submitted a “Hospital Provider” application to PBH or another LME/MCO (except for Western Highlands), you may provide a copy of that application to CenterPoint. If you choose to provide a copy, you must sign and submit page 14 of the “CenterPoint Provider Hospital Based Inpatient and Outpatient Psychiatric Services Application” and a signed and dated Letter of Attestation. All information must be current within 6 months of the date of the signature.

The application “checklist” and the “Instructions for CenterPoint Enrollment of Hospital” will guide you in completion of materials. Forms may be accessed via the links below:

• CenterPoint Provider Enrollment / Medicaid Reimbursement Request Form - Cover Letter
• Inpatient and Emergency Department Services Provider Enrollment / Medicaid Reimbursement
  Request Form
• Authorization to File Application for Services for Hospitals and Inpatient Psychiatric Providers
• CenterPoint Provider Hospital Based Inpatient and Outpatient Psychiatric Services Application
• Letter of Attestation
• Sample Hospital Procurement Contract for Review
• W-9 Request for Taxpayer Identification Number and Certification Form

Please be sure the application documents submitted are complete and accurate to avoid delays.

***IF YOU CHOOSE NOT TO PARTICIPATE***

Providers who choose not to participate will be unable to deliver and be reimbursed for Medicaid services as of February 1, 2013. If you choose not to participate in the CenterPoint Network please notify us immediately at Credential@cphs.or. You and/or your hospital will be responsible for appropriately transitioning consumers to a CenterPoint provider who is contracted with CenterPoint as of February 1, 2013

**IMPORTANT**

1. Incomplete application packets will delay the credentialing, contract and enrollment process.
2. Please assure that all required attachments are submitted with your application.

Please send all questions or inquiries to our dedicated credentialing email address at Credential@cphs.org to help us manage volume and route inquiries appropriately.