FMBS Provider Credentialing Onboarding
Date
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Month
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Day
Year
Date
Provider Name
*
Date of Birth
*
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Month
-
Day
Year
Date
Personal Cell Phone
*
Personal Email
*
SSN
*
State License Number
*
State License
*
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NPI - Personal
*
CAQH #
*
Practice Details
*
Practice Name
Practice Address
Practice Phone #
Practice Fax #
Practice TIN/EIN
Practice Billing NPI
Curriculum Vitae
*
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CURRENT Malpractice Insurance
*
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W9
*
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DEA Number
*
DEA
*
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Medicare Number
Do you Have a PECOS account
State Medicaid Number
I Understand:
*
Providers that are NOT enrolled in the FMBS account management tier, will be invoiced a fee
The credentialing process from start to finish takes about 120 business days
My CAQH account and licenses must be current at the time of request
Please share any additional information we may need to know
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