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Provider Intake Form

  
SECTION 1: PROVIDER AND GROUP INFORMATION
* - required fields
Provider Group Name *  
Address *  
City *  
State / Province *  
Name
The name of the person
entering the form.
  
Phone *  
What specialties / practice areas do you provide? *
(e.g. orthopedics, cardiology, primary-care, etc.)
  
Are your providers? * Independent
Employed by hospital system 		 
Are all of your physicians board certified? *  
Are those who are not board certified board eligible?  
Please list the city, state, and country of each of your locations *  
Tax ID *  
NPI Number *  
Does your organization or any of your providers practicing within your organization hold an ownership interest in a hospital/ASC/etc.? *
(If yes, please describe below)
  
Hospital/ASC/etc. Ownership  
How did you hear about NOVO Health?  
Primary Contact
Name *  
Phone *  
Title *  
Email *  
Person authorized to enter into an agreement with NOVO Health
Name *  
Phone *  
Title *  
Email *  
SECTION 2: PROVIDER / PAYER CONTRACTING
Please list any independent practice association, physician-hospital organization, accountable care organization, or other third-party association/coalition/organization through which you obtain any payer contract(s) *
 
Does your organization hold any payer contracts directly with payers other than Medicare/Medicaid (e.g. commercial insurance programs, self-funded health plans, etc.)? *  
Are you a participating provider for any of the following?
(click all that apply)
  
Are you currently participating in a bundle payment program? *  
If yes, Please describe  
Are you currently providing on-site/or near-site services to any 3rd party company (e.g. staffing an on-site clinic for a self-funded employer group)? *  
Please tell us anything else important for us to understand about your provider group  
SECTION 3: DIRECT CONTRACTING PARTICIPATION CONFIDENTIALITY AGREEMENT
NOVO Health may make commercially sensitive information available to Provider Group in response to the information you have provided on this form. Examples of such information would include proposed contracts for your review, pricing, and other proprietary information. Before disclosing these types of sensitive information, we are requesting your agreement to keep such information confidential.

Please review the statements below and choose one that applies to you:
On behalf of the Provider Group listed at the top of this form, I agree that if NOVO Health makes commercially sensitive information available to the Provider Group about NOVO Health programs (such as pricing, contracts and other proprietary information), the Provider Group will keep that information confidential. The Provider Group will use reasonable means to protect such information, including the means it uses to protect the confidential information of its own business. If Provider Group chooses not to enter into an agreement with NOVO Health, or ends its participation in NOVO Health program, Provider Group will destroy or return NOVO Health's confidential information.

By typing my name in the space below, I intend to electronically sign, agree to, and become bound by the Confidentiality Statement

I am a third-party representative or am otherwise unauthorized to make this commitment that Provider Group will keep NOVO Health's commercially sensitive information confidential. I recognize that in order to receive commercially sensitive information from NOVO Health, an authorized representative will need to provide NOVO Health with an agreement to keep it confidential.