PROVIDER INTAKE & ENROLLMENT FORM

Provider Intake & Enrollment Form

ALL INFORMATION WITH * NEEDS TO BE SUBMITTED SO THE PROCESS WOULD NOT DELAY

Items required for provider enrollment. We would need a copy of the following to complete the credentialing and provider enrollment process.

*IRS confimation Letter of your tax idenification number

*Void Business check or letter from bank

*Curriculum Vitae

*W-9 Form - If you don't have one we will send one to have you sign.

*Medical School Diploma

*Certificate of Professional Liability Insurance

*Professional License or Certification type

*If these items are unfamiliar to you, please let us know.

**It can take anywhere from 60-180 days for provider credentialing, but that is only if you provide all of the information correctly the first time. If there is a petition process, lobbying, or appealing, it can take between 190-220 business days.

TYPE OF SERVICES REQUESTING

Provider Name

First NameLast Name

Date of Birth

Date

Social Security Number

individual NPI Type 1

Business Name

Business Name/ Doing Business AS

Tax identification number

Group NPI Type 2

License Number

CAQH Number

CAQH Username:

Provider License Type

Specialty

State & Country of Birth

PECO Username

Personal Email Address

Business Email Address

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

1. Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

2. Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Fax Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Degree Type

Michigan Physician License Number

example@example.com

Michigan Controlled Substance License

Certificate of Professional Liability Insurance Number

Provide any pending, settled, arbitrated, mediated or litigated professional liability actions within the past 10 years

Professional license or Certification type

Medicare Identification number

Access to your CHAMPS application

Commercial Insurance Plans

Medicaid Insurance Plans

Medicare Insurance Plans

Office Days & Time

Telehealth Services

Indicate Specialties

Age Ranges 0-12 (Child) 13-17(Adolescent) 18-64 (Adult

Signature

File Upload

My Products

Product Name

Free Quantity

Total

Credit Card