Site Verification Form
Last updated
Last updated
KSB supports site/provider creation and updates via a site verification form. This efficiently takes in the information on the form related to any existing or new site, as well as any provider personnel changes, and updates them within the program. The Site Verification Form has two tabs: Site Info and Provider Info.
Site info will contain general site fields such as clinic name, address, contact information, and NPI number. The EMR information, associated MCPs, and IPAs may also be listed here. On the bottom, health plans need to include the DHCS Site ID for this site, new or existing. This helps the program decide if a new site needs to be created, or an existing site needs to be updated.
Provider Info will allow for any adjustment in provider personnel. This includes the adding/removal of providers from the site, as well as any update in existing providers' information. This is decided by the first column A : Add, Delete, Update, and No Change.
The input fields here include:
Provider Name
Provider Title
PCP Specialty Type
Provider License Number
Provider NPI Number
PCP(Y/N)
Practicing at this location
Uploading to KSB
To upload a Site Verification Form to KSB, navigate to the Site Data page and select the "Upload Site Verification Form (SVF)" button. You will be prompted to select the file for upload. Once uploaded, the site will be created or updated.
