[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-279960-105":3,"doc-detail-279960-en":81,"detail-sidebar-cat-1-en-105":98},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","workerscompensation-ppo-character-and-competence-review-information-application-form","WORKERS'COMPENSATION PPO CHARACTER AND COMPETENCE REVIEW INFORMATION - Application form","","Workers' compensation PPO character and competence review information gathers required personal, employment, educational, licensing, and legal-disclosure details from specified individuals including owners, governing body members, partners, and the administrator and medical director. Section I captures identifying data, current or proposed position, and a ten-year employment history with supervisor and responsibilities. It also collects education, prior name or alias use, criminal and civil actions, securities/insurance/health-law issues, licensing history, fidelity bond questions, and related attachments with affidavits and notarization.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/workerscompensation-ppo-character-and-competence-review-information-application-form/279960/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/workerscompensation-ppo-character-and-competence-review-information-application-form/279960.png","ImageObject",442,249,{"name":42,"@type":43},"Skyler","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-16",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",8,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who must complete the sections and affidavits for the Workers' Compensation PPO character review?","Question",{"text":63,"@type":64},"Owners of record/beneficial owners, members of the governing body and controlling persons, partners, and the administrator and medical director must complete the instructions and provide the affidavits.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What does Section I require for personal and employment history?",{"text":68,"@type":64},"It requires personal identifying information, current or proposed position details, and a ten-year employment history starting with the most recent job, including employer information, dates, supervisor reference, and responsibilities.",{"name":70,"@type":61,"acceptedAnswer":71},"What legal and licensing questions must be answered in the character and competence review?",{"text":72,"@type":64},"The form asks about name changes or aliases, indictments/convictions and pending criminal or civil actions, involvement in insolvency or cease-and-desist orders, licensing denials or sanctions, regulatory enforcement actions, and fidelity bond requirements and claims.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},279960,1790460695,{"code":4,"msg":82,"data":83},"success",{"doc_id":79,"user_id":84,"nickname":42,"user_avatar":85,"doc_module":22,"category_id":86,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":87,"file_id":88,"file_url":89,"file_type":90,"file_size":91,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":92,"language":93,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":94,"faqs":95,"seo_title":96,"seo_description":12,"update_tm":97,"read_time":33},2336464648746,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c",17,"# WORKERS'COMPENSATION PPO CHARACTER AND COMPETENCE REVIEW INFORMATION\n\nINSTRUCTIONS:Section I-II should be duplicated and forwarded to each of the following individuals for completion:  \n·  All owners of record or beneficial owners;  \n·All members of the governing body,officers,directors and controling persons.Controlling person for the purpose of this section means anyperson who has the ability directly or indirectly,to direct or cause the direction of the management or policies of a corporation partnership orother entity.Control shall be presumed to exist if any person directly owns,controls or holds the power to vote ten(10)percent or more ofthe voting securities or voting rights of any other person or is a corporate member of a not-for-profit corporation;  \n·  All partners of a partnership;and  \n·  The administrator and the medical director.  \nAt the end of Section I is an afidavit that must be completed by each individual listed above.Without all igned and notarized affidavits thisapplication will be considered incomplete.  \nOmission of any information requested may lead to exclusionof the applicant from consideration for a Certificate of Authority or revocation of thecertificate if such certificate is already awarded.  \n## I)   PERSONALQUALIFYING INFORMATION\n\n\n| A.  PERSONAL IDENTIFYING   |  |  |\n| --- | --- | --- |\n| NAME(Last)   | (First)   | (Middle Initial)   |\n| STREET ADDRESS   |  |  |\n\n\n| CITY   | STATE   |  | ZIP CODE   |\n| --- | --- | --- | --- |\n| TELEPHONE NUMBER   | (Area Code)   |  |  |\n\nBUSINESS NAME AND ADDRESSDATE OF BIRTHMONTH/DAY/YEARPLACE OF BIRTHSOCIAL SECURITY\\#CURRENT OR PROPOSED POSITION WITH PROPOSED PPO  \n\n| CITY   | STATE   | ZIP CODE   |\n| --- | --- | --- |\n| TELEPHONE NUMBER(Area Code)   |  |  |\n\n## B.   INDIVIDUAL EMPLOYMENT HISTORY\n\nStart with MOSTRECENT employment and include employment for the last ten(10)years.A resume may be included but any aditionalinformation requested below and not contained in such resume should be added.Photocopy and attach additional sheets if necessary.      \nNAME OF EMPLOYER  \nSTREET ADDRESS OF EMPLOYER  \n\n| CITY   | STATE   | ZIP CODE   |\n| --- | --- | --- |\n| DATES OF EMPLOYMENT   | TYPE OF BUSINESS   |  |\n| FROM:  \u003Cbr>TO:   |  |  |\n| NAME OF SUPERVISOR/REFERENCE   | TELEPHONE NUMBER   |  |\n| POSITION/RESPONSIBILITIES   |  |  |\n\nREASON FOR DEPARTURE  \nDEDUCATIONALHISTORY(High School and Subsequent Education)  \n   \n## E HISTORY OF ANY LEGAL ACTIONS\n\n1.Have you ever changed your name or used an alias?  \n□YES  \n□No  \nNOTE:If\"YES\"attach an explanation including other name(s)date(s)and the reason(s)for each change.  \n2.Except for minor traffic violations,have you ever been indictedor been convicted or had a sentence imposed or suspended,orbeen pardoned of a conviction for any crime?  \n□YES  \n□No  \n3.Are there any criminal actions pending against you?  \nNO  \nYES  \n4.Have you ever been named as a defendant in any civil action orproceeding in which there was an issue of morale turpitude,including but not limited to fraud or breach of fiduciaryresponsibility?  \nYES  \nNO  \nNOTE:If\"YES,\"to 2,3,or 4 attach explanation(s)including thedate of the action or proceeding,place(county of the filing),the civildocket number,if available,and the disposition of thecase,ifany.  \n5.Have you ever been an officer,trustee,management employeeor controlling stockholder of a company which,while youoccupied any such position or served in any such capacity withrespect to it:  \na.  became insolvent,declared or was forced to declare bankruptcyor was placed in receivership or conservatorship?  \nNO  \nYES  \n   \n\n| Type of License  \u003Cbr>(including specialty)   | Institution Granting License and Address   | Date Received   | Date of Expiration   |\n| --- | --- | --- | --- |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n\n   \n\n| Institution   | Address   | Attended  \u003Cbr>From/to   | Degree   | Date Received   |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n\n   \nb.  was e","cbCaicvvG0idalCp","https://ap.wps.com/l/cbCaicvvG0idalCp","pdf",303349,10,"English","# WORKERS'COMPENSATION PPO CHARACTER AND COMPETENCE REVIEW INFORMATION\n## Section I) PERSONAL QUALIFYING INFORMATION\n## A. PERSONAL IDENTIFYING\n## B. INDIVIDUAL EMPLOYMENT HISTORY\n## E HISTORY OF ANY LEGAL ACTIONS\n## II) AFFILIATION WITH OTHER HEALTHCARE OPERATIONS","[{\"question\":\"Who must complete the sections and affidavits for the Workers' Compensation PPO character review?\",\"answer\":\"Owners of record/beneficial owners, members of the governing body and controlling persons, partners, and the administrator and medical director must complete the instructions and provide the affidavits.\"},{\"question\":\"What does Section I require for personal and employment history?\",\"answer\":\"It requires personal identifying information, current or proposed position details, and a ten-year employment history starting with the most recent job, including employer information, dates, supervisor reference, and responsibilities.\"},{\"question\":\"What legal and licensing questions must be answered in the character and competence review?\",\"answer\":\"The form asks about name changes or aliases, indictments/convictions and pending criminal or civil actions, involvement in insolvency or cease-and-desist orders, licensing denials or sanctions, regulatory enforcement actions, and fidelity bond requirements and claims.\"}]","WORKERS'COMPENSATION PPO CHARACTER AND COMPETENCE REVIEW INFORMATION - Application form | PDF",1789530652,{"code":4,"msg":82,"data":99},[100,105,110,115,120,125,128,133,138],{"id":101,"doc_module":22,"doc_module_name":25,"category_name":102,"show_sort_weight":103,"slug":104},11,"Presentations",90,"presentations",{"id":106,"doc_module":22,"doc_module_name":25,"category_name":107,"show_sort_weight":108,"slug":109},12,"Resumes",80,"resumes",{"id":111,"doc_module":22,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},14,"Invoices",70,"invoices",{"id":116,"doc_module":22,"doc_module_name":25,"category_name":117,"show_sort_weight":118,"slug":119},15,"Posters",60,"posters",{"id":121,"doc_module":22,"doc_module_name":25,"category_name":122,"show_sort_weight":123,"slug":124},16,"Social Media",50,"social-media",{"id":86,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":126,"slug":127},40,"forms",{"id":129,"doc_module":22,"doc_module_name":25,"category_name":130,"show_sort_weight":131,"slug":132},18,"Letters",30,"letters",{"id":134,"doc_module":22,"doc_module_name":25,"category_name":135,"show_sort_weight":136,"slug":137},21,"Paper Templates",5,"papers-templates",{"id":139,"doc_module":22,"doc_module_name":25,"category_name":140,"show_sort_weight":4,"slug":141},158,"General","general-158"]