Credentialing Client Discovery Form

1. Privacy, Confidentiality, and Security of Credentialing Documents

TriumpHealth is committed to protecting confidential client, provider, and business information in accordance with applicable privacy and data security laws, including HIPAA where applicable.

The Client agrees to submit sensitive credentialing and enrollment documents, including licenses, insurance records, tax documents, provider records, and other confidential information, only through TriumpHealth's approved secure transmission methods.

Unsecured email, fax, or postal transmission should not be used unless specifically authorized by TriumpHealth through an approved process.

Where applicable, the parties' separate Business Associate Agreement (BAA) shall govern the handling of Protected Health Information.

2. Technology Platform and Document Submission Requirements

The Client agrees to upload required credentialing documents through TriumpHealth's designated secure ShareFile portal or another secure method expressly approved by TriumpHealth.

The Client is responsible for providing complete, accurate, legible, and current documents within the requested project timelines.

Incomplete, missing, expired, or delayed documentation may affect processing schedules, application submissions, effective dates, and payer determinations. TriumpHealth shall not be responsible for delays directly attributable to the Client's failure to provide required information or documentation in a timely manner.

3. CAQH, ADA, and Payer Portal Access

Where applicable, the Client is responsible for maintaining complete, accurate, current, and properly attested CAQH, ADA, and other applicable credentialing profiles.

The Client agrees to provide TriumpHealth with appropriate authorized access, delegation, or permissions necessary to perform the contracted services, subject to applicable portal and payer requirements.

The Client and individual providers remain responsible for all attestations, signatures, identity verifications, and approvals that must legally or contractually be completed by the provider or authorized representative.

TriumpHealth shall not be responsible for credentialing delays, denials, or participation issues directly resulting from unavailable access, incomplete profiles, expired attestations, or inaccurate information supplied or maintained by the Client.

4. Business and Service Location Verification

The Client certifies that all business, practice, billing, and service-location addresses disclosed in this Discovery Form are accurate and reflect the actual nature of the Client's operations.

Locations must satisfy applicable federal, state, licensing, and payer enrollment requirements. Virtual offices, P.O. Boxes, mailbox services, residential addresses, mobile-service arrangements, and telehealth locations may be acceptable or restricted depending on the applicable provider type, payer, and enrollment requirements.

The Client acknowledges that inaccurate or noncompliant location information may result in application delays, site-visit failures, denials, payment disruptions, or other payer actions.

5. Licensure, Supervision, Accreditation, and Regulatory Compliance

The Client is responsible for maintaining all applicable professional licenses, certifications, business registrations, permits, supervising or collaborating provider arrangements, accreditation, insurance coverage, and other requirements necessary to operate and provide the intended healthcare services.

TriumpHealth may identify credentialing-related requirements during the enrollment process; however, unless expressly included in the executed Service Agreement, TriumpHealth does not provide legal advice, independently certify regulatory compliance, or guarantee satisfaction of licensing, accreditation, clinical supervision, or operational requirements.

The Client remains responsible for ensuring that its providers, facilities, operations, and clinical services comply with applicable laws, regulations, and payer requirements.

6. Client Information Accuracy and Ongoing Updates

The Client certifies that all information and documentation provided to TriumpHealth is true, complete, accurate, and current to the best of the Client's knowledge.

The Client agrees to promptly notify TriumpHealth of any material changes affecting credentialing or enrollment, including ownership, Tax Identification Number (TIN), National Provider Identifier (NPI), provider affiliations, licenses, addresses, practice locations, services, or payer participation.

TriumpHealth may rely upon information and documentation supplied or approved by the Client without independently verifying every representation, except where verification is expressly included in the contracted Scope of Work.

7. Credentialing and Enrollment Authorization

The Client authorizes TriumpHealth, within the scope of the executed Service Agreement, to use the information and documentation provided for preparing, submitting, tracking, and following up on credentialing, contracting, and payer enrollment applications.

This authorization does not replace any provider-specific signature, attestation, payer authorization, government enrollment authorization, or other approval required by law, regulation, or applicable portal terms.

8. Payer Approval, Effective Dates, and Reimbursement Disclaimer

The Client acknowledges that credentialing, enrollment, contracting, network participation, effective dates, and reimbursement are subject to applicable payer policies, eligibility requirements, network availability, and payer determinations.

TriumpHealth does not guarantee payer approval, contract acceptance, network participation, enrollment effective dates, retroactive effective dates, reimbursement rates, or payment of claims.

TriumpHealth shall not be responsible for unfavorable payer determinations or delays beyond its reasonable control, except to the extent attributable to TriumpHealth's failure to perform its contractual obligations.

9. Pricing, Client Delays, and Additional Services

Pricing and services are governed by the executed Service Agreement and applicable Scope of Work.

The agreed pricing assumes timely Client cooperation, accurate documentation, reasonable access to required information, and compliance with the agreed credentialing workflow.

Material changes in provider count, practice locations, payer requirements, enrollment structure, or requested services may require a revised Scope of Work and additional fees, subject to written agreement between the parties.

Client-caused delays may affect project timelines but shall not automatically modify payment obligations established under the executed Service Agreement.

10. Scope of Work and Agreement Precedence

This Discovery Form is intended solely to collect operational, administrative, and credentialing information necessary to perform the services described in the executed Service Agreement.

It does not independently expand, modify, or replace the contracted Scope of Work or create additional service obligations.

In the event of any conflict or inconsistency, the executed Service Agreement, including its agreed order of precedence and any applicable written amendments, shall control.

11. Client Certification and Acknowledgment

By submitting this Discovery Form, I certify that:

I am authorized to provide the requested information on behalf of the Client.

The information provided is true, complete, and accurate to the best of my knowledge.

I understand the Client's responsibility to provide required information, maintain applicable licenses and approvals, and promptly disclose material changes.

I authorize TriumpHealth to use the information for the credentialing and payer enrollment activities covered by the executed Service Agreement, subject to any additional authorizations required.

I acknowledge that submission of this Discovery Form does not guarantee payer approval, participation, contracting, reimbursement, or effective dates.

I have reviewed and acknowledge the requirements and limitations described above.