Provider Questionnaire & Signature Releases

If you are a provider working on behalf of an employer that has contracted with Palmetto Credentialing, please contact your supervisor with any questions. If you are a solo provider, please do not hesitate to contact me directly.

Provider Name:*

First NameLast Name

Have you held, or do you hold an individual contract with any insurance panel?*

YesNoUnknown

If you answered "yes", please list current panels on which you participate:

Current insurance panel participation

Are you currently in the credentialing process for another practice?*

YesNoUnknown

If you answered "yes", please list current panels and estimate of initial submission date:

Current credentialing in process

Have you ever been denied network participation on any insurance panel?

YesNo

If you answered "yes", please explain:

Denial of participation explained

Have you ever had any disciplinary, administrative, civil or criminal actions taken against you in a professional capacity?

YesNo

If you answered "yes", please explain:

Disciplinary, administrative, civil or criminal actions explained

SIGNATURE RELEASES:

Palmetto Credentialing (Sarah Ekvall) will keep the provider and employer (if applicable), informed of all processes taking place. since enrollment and credentialing requires many signatures, please read the following carefully and specify your preference.

This section applies to all providers.

I give permission for Palmetto Credentialing (Sarah Ekvall) to act as my authorized representative and to sign as such on all documents that are applicable for credentialing, enrollments and updates to panels and profiles.

YesNo

By selecting "no", you understand that all documents, including those that allow for authorized representative signatures, will be sent directly to you, the provider. If the signature is required to be in ink (not scanned or photocopied), you will send the original documents via USPS to Palmetto Credentialing (Sarah Ekvall). Please understand that this option will delay the credentialing process and can cause a timeliness issue with pending contracting. You, the provider, will take full responsibility for any delays or issues that relate directly to timeliness.

I give permission for Palmetto Credentialing (Sarah Ekvall) to sign for me (physically and electronically) on my behalf for all documents that are applicable for credentialing, enrollments and updates to panels and profiles. **Please note that you will be informed before anything is signed for you.

YesNo

By selecting "no", you understand that all documents that require your direct signature will be sent directly to you, the provider. If the signature is required to be in ink (not scanned or photocopied), you will send the original documents via USPS to Palmetto Credentialing (Sarah Ekvall). Please understand that this option will delay the credentialing process and can cause a timeliness issue with pending contracting. You, the provider, will take full responsibility for any delays or issues that relate directly to timeliness.

I give permission for Palmetto Credentialing (Sarah Ekvall) to sign for me (physically and electronically) on my behalf for updates and changes to my CAQH and NPI listings. **Please note that you will be informed before anything is signed for you.

YesNo

By selecting "no", you understand that you, the provider, will be responsible to attest your own CAQH profile and authorize your own NPI listing updates and changes. In doing so, you understand that this can cause a timeliness issue and will take responsibility for any delays caused by this. You also understand that you are responsible to sign any changes to your NPI listing. In doing so, you will take responsibility to sign the updates / applications once received via USPS from Palmetto Credentialing (Sarah Ekvall). You will also take the responsibility to send any completed updates / applications via USPS to the NPPES headquarters (if applicable).

I have read, understood and selected my preferences for signature releases. I take full responsibility for the preferences I have chosen. If I choose to change my preferences, I will do so in writing and sign a new release at the time of change.