APPLY FORM | Credentialing Profes

Credentialing On-Boarding Form

Provider Name

Gender

Practice Name

Practice Address

County

Phone Number

Fax Number

Billing Address

Billing Contact Name

Owner Name

Email Address

Office Credentialing Contact Name

Start Date at Practice

Practice Hours of Operation

Degree

Specialty

Board Certification

Social Security Number

Driver License Number

Driver License Expiration Date

City / State / Country of Birth

Birth Date

Tax ID (Or Social Security Number if no Tax ID)

National Provider Number (NPI) - Individual

National Provider Number (NPI) - Group

CAQH Number

CAQH Username

CAQH Password

State License Number

License Issuing State

Medical School Name and Address

Medical School - Dates Attended

Insurance Name and Address

Insurance Policy Number

Each Incident / Occurance

Aggregate

Effective Dates

Expiration Date

Languages Spoken

DEA Number

DEA Issue Date and State

DEA Expiration Date

Upload Current CV /Resume'

Upload Malpractice Insurance Cetificate

Upload DEA Cetificate

Upload Medcal License

Upload Board Certification Certificate

Upload Current Driver License

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