CAP Form

Provider Type/Specialty: *

Line of Business: *

Note: Choose Medicaid and Medicare only if your practice site was audited for both Medicaid and Medicare and the corrective action plan (CAP) covers all failed standards.

Practice Description: *

Corrective Action Plan Status Site agrees to become compliant with all access standards Site is currently compliant with all access standards listed as failed on the report card Site is unable to meet one or more of the access standards Site is unable to interpret the accessibility audit results: Outreach from Provider Representative requested Site is closed or has moved to a different location: Outreach from Provider Representative requested

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PROVIDER ACCESS CORRECTIVE ACTION PLAN (CAP) ONLINE SUBMISSION FORM

STEP 1: Complete the practice site detail fields below

STEP 2: Please check the box below that identifies your practice site's action plan status

STEP 3: Please identify your site's barrier(s) to meeting the provider access standards

STEP 4: Please identify the corrective action(s) your site has taken to ensure the access standards are met

STEP 5: By entering your name and title below you are attesting that your practice has completed staff training and a practice self-assessment to ensure that you meet Highmark Health Options access standards

Attestation* (Should be completed by an Office Administrator or Corporate compliance)