Credentialing Onboarding Form (New Clients)

Welcome!

From here, we'll take you through our credentialing onboarding form. We've curated this brief questionnaire designed to provide us with all of the necessary details that we'll need to in order to get bizzy submitting your applciations.

Before continuing, please ensure that you have the following items on hand:
- PDF copy and details of your license(s)
- PDF copy and details of your liability insurance
- PDF copy of your resume/CV
If applicable, we may also need PDF copies and details of your:
- Prescriptive Authority Agreement
- DEA Registration Certificate
- CDS Registration Certificate
Please carefully read the following terms and conditions below before continuing.

- Legal Name*
  
  First NameMiddle NameLast Name
- National Provider Identifier (NPI I)*
- Clinician Primary Degree Type:*
- Date Of Birth:*
  
  MonthDayYear
  Date
- Primary Contact Email:*
- Primary Contact Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Legal Name of Primary Practice Location (as it appears on the W-9)
- Tax ID
- GroupIndividual
- Organization (Type 2) NPI

- In this section, we ask for your CAQH details so that we can monitor and update your profile to ensure that your credentialing applications is actively moving through each step in the process.
  
  We'll use your CAQH username and password to log in and review your profile to ensure your profile has all the information that all insurance payers need to process your application.
  
  If you'd feel more comfortable sharing a copy of your state application, you can visit this link for instructions on how to download a .pdf copy that you can send as an attachment.
  
  *Please note: You must select one of the options to share your CAQH profile.
- CAQH Username:
- CAQH Password:
- CAQH #:
- Date of Last CAQH Attestation
  
  MonthDayYear
  Date
- Attach a copy of your state application here
  
  Cancelof

- Please list any variations of your name that may be associated with your NPI (I), license, or degree (maiden name, nick name, etc.).
- Clinician Address*
- Gender*
- Citizenship:*
- Race/Ethnicity*
- City, State, & Country of Birth:*
- Languages Spoken other than English:
- Clinician Social Security #:*
- Clinician Professional License or Certification:*
- Clinician License #:*
- Issuing Entity of License or Certification*
- License Issue Date*
  
  MonthDayYear
  Date
- License Expiration Date*
  
  MonthDayYear
  Date
- Please Upload a Copy Of Your License*
  
  Cancelof
- YesNo

- Name of Supervisor
  If Applicable
- Supervisor License Type
  If Applicable
- Supervisor National Provider Identifier (NPI I)
  If Applicable
- Supervisor Contact Email
  If Applicable
- Please upload a copy of Supervisor/Supervisee agreement *
  
  See below for an example
  Cancelof

- I am a participating Medicare providerI have a DEA (Drug Enforcement Agency) Registration CertificateI have a Board CertificationI have a Hospital AfilliationNone of the above

- Medicare ID #:
  (If Applicable)
- Medicaid/Medi-cal ID #:
  (If Applicable)
- Medicare Issue Date
  
  MonthDayYear
  Date
- Medicare Expiration Date
  
  MonthDayYear
  Date
- Medicaid/Medi-Cal Issue Date
  
  MonthDayYear
  Date
- Medicare Expiration Date
  
  MonthDayYear
  Date
- Name of Issuing Board:
- Specialty
  Include Subspecialty
- Certification Date:
  
  MonthDayYear
  Date
- Recertified Date:
  
  MonthDayYear
  Date
- Expiration Date:
  
  MonthDayYear
  Date
- Maintenance of Certification (MOC) Verification Date:
- If not certified, describe your intent for certification, if any, and date of eligibility for certification.
- Hospital 1 Name
- Hospital 1 Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Hospital 1 Date To:
  
  MonthDayYear
  Date
- Hospital 1 Date From:
  
  MonthDayYear
  Date
- Hospital 1 Address
  
  Hospital 1 Street Address
  
  Hospital 1 Street Address Line 2
  
  Hospital 1 CityHospital 1 State / Province
  
  Hospital 1 Postal / Zip Code
- DEA #:
  (If Applicable)
- Please Upload a Copy Of Your DEA Certificate
  
  (If Applicable)
  Cancelof
- DEA Issue Date:
  (If Applicable)
- DEA Expiration Date:
  (If Applicable)
- Nurse Practitioner Supervisor:
  (If Applicable)
- Physician Assistant Supervisor:
  (If Applicable)

- Current Insurance Carrier:*
- Policy Number:*
- Effective Date:*
  
  MonthDayYear
  Date
- Expiration Date:*
  
  MonthDayYear
  Date
- Per Claim Amount:*
- Per Aggregate Amount:*
- Malpractice Insurance Facesheet*
  
  Cancelof

- Primary Practice Location
- Tax ID
- Organization (Type 2) NPI
- Practice Location Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Practice Location Email Address*
  example@example.com
- Appointment Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- In-OfficeTelehealth
- In-Office Availability
- Telehealth Availability
- Provider After Hours Arrangements
  (i.e. voicemail instructing patients if it is a life-threatening emergency to call 911 or give a crisis line information)

- Please list all applicable and relevant education/training. Use the button below to add additional records.*

- Please list your current employment and relevant employment history.
- Please list your current employment and relevant employment history. Use the button below to add additional records.*
- CV or Resume*
  
  Cancelof

- Please provide a minimum of 3 references.*

- I certify that the above facts are true to the best of my knowledge and belief. *
- Should be Empty: