NY Manual
SHP Manual

New York Provider Manual
II-A Credentialing Requirements | II-C Interpretative Guidelines for the Office Site Evaluation Form

Appendix II-B — Healthfirst Office Site Evaluation Form 

PROVIDER NAME:                                                                       SPECIALTY:                                          
 
ADDRESS:                                                                                                                                                 
 
PROVIDER ID:                                                                                                                                           
 
Office Hours:
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
 
 
 
 
 
 
 
 
Reason for Visit: 
c Initial Site Visit  c Recredentialing Visit  c Routine Visit   c Other                                                    
  
PHYSICAL ACCESSIBILITY
YES
NO
N/A
COMMENTS
Clearly marked office sign
 
 
 
 
Handicapped parking available
 
 
 
 
Entrance to facility handicapped accessible
 
 
 
 
Exam rooms handicapped accessible
 
 
 
 
Patient restrooms properly equipped and handicapped accessible
 
 
 
 
 
 
 
 
 
PHYSICAL APPEARANCE
YES
NO
N/A
COMMENTS
Facility is clean and well maintained
 
 
 
 
Restrooms AND exam rooms clean
 
 
 
 
Provider hand washing area available
 
 
 
 
Adequate patient seating available
 
 
 
 
Adequate number of exam rooms
 
 
 
 
 
 
 
 
 
FIRE AND SAFETY ISSUES
YES
NO
N/A
COMMENTS
Exits are clearly marked and accessible
 
 
 
 
Fire safety equipment present (alarm/detector AND extinguisher)
 
 
 
 
Hazardous waste disposal process in place (“Red bag system”)
 
 
 
 
Impervious container for needle/syringe disposal
 
 
 
 
Emergency kit available and includes Ambu bag/mask – Emergency drugs
 
 
 
 
 
 
 
 
 
X-RAY / LABORATORY / PHARMACEUTICALS
YES
NO
N/A
COMMENTS
Current X-Ray/Radiological Equipment inspection certificate
 
 
 
 
Current CLIA certificate or certificate of waiver
 
 
 
 
Medication accessible only to authorized personnel
 
 
 
 
Prescription pad, needles and syringes are inaccessible to patients
 
 
 
 
 
 
 
 
 
MEDICAL RECORDKEEPING/CONFIDENTIALITY
YES
NO
N/A
COMMENTS
Current medical records are accessible only to authorized staff
 
 
 
 
Medical records are kept in a secured location after hours
 
 
 
 
Private consultation space available
 
 
 
 
Use of Mental Health Assessment Tool *
 
 
 
 
Standardized medical record format
 
 
 
 
*If the provider office is using a tool other than Healthfirst’s, please provide a copy.                                               Rev0205
 
Healthfirst Office Site Evaluation Form (continued)
 
PROVIDER AVAILABILTY
YES
NO
N/A
COMMENTS
Maximum wait time for appointments – 1 hour for a scheduled visit
Medicare patients only – 30 minute or less wait-time
 
 
 
 
Maximum wait time for appointments – 2 hours for a walk-in (non-emergent condition)
 
 
 
 
Emergency Care: Immediately upon presentation
 
 
 
 
Urgent medical care appointment within 48 hours
 
 
 
 
Non-urgent “sick visits” within 48-72 hours
 
 
 
 
New patient appointments within 12 weeks (4 weeks for HIV positive members)
Pediatrics – well child care 4 weeks
 
 
 
 
Routine appointments within 4 weeks
 
 
 
 
24 hour coverage available/7 days a week (list method)
 
 
 
 
Physician MUST be available minimum of 16 hours/week at each site
(Medicare and Commercial only minimum of 10 hours/ 2 days)
 
 
 
 
 
Name and address of practitioner(s) providing coverage:__________________________________________________________
                                                                                    __________________________________________________________
                                                                                    __________________________________________________________
                                                                                    __________________________________________________________
 
Is the practitioner providing coverage a Healthfirst provider?              Yes                                      No
 
Comments:
 
 
 
 
 
 
 
Score: ________________
 
Healthfirst Representative:_______________________________________________ Date: ______________________________
 
I acknowledge that the above review has taken place and that I am not necessarily in agreement with the above listed responses.
 
Provider / Staff Acknowledgment Signature: ___________________________________ Date: _______________________