Request a TIOPA Application

Provider Name*

First NameLast Name

Provider Title*

Provider NPI*

Provider Type*

PCPSPECHOSPBehavior Health

Group Legal Business Name*

Do you have multiple TINs to credential with TIOPA?*

YesNo

Additional TINs Legal Business Name

Telehealth*

YesNo

Applications Request Type*

Specialty

Are you switching IPAs or moving from Direct Contracts? *This is TIN specific**

Yes - changing IPAsNo - neither applyYes - I have existing direct contractsI don't know

Email where Application is sent MUST BE UNIQUE TO PROVIDER*

example@example.com

Admin Contact Email (Can be a shared email)

example@example.com

Do you have an additional Admin email you would like to add?

YesNo

Add all additional emails here - please use a comma to separate emails.

EX: John Smith - jsmith@email.com, Jane Doe - Jane@email.com

Contact Phone Number

Please enter a valid phone number. We will only call if there is an issue with your email.

Does the Provider have a CAQH number?

Yes, and I am willing to provide it.Yes, but I prefer not to provide it.No, I do not have a CAQH number.I am unsure about my CAQH number status.

Are you a Behavioral Health Provider?

YesNo

IMPORTANT

If you've chosen the paper application, follow the specific instructions. Otherwise, simply scroll down and hit "Submit" below. Failure to do so will result in your application request not being received.

Application Forms

Please select the appropriate application form from the options below. After downloading and completing the form, kindly proceed to upload it in the designated section provided at the end of this page.

Physician Applications

Physician Application
Physician Application - Behavioral Health

Non-Physician Applications

Allied Health Application
Allied Health Application - Behavioral Health

All Providers

Extra Services

Upload Your Application

Please upload your completed paper application, malpractice insurance documents, W-9 form, and any other required documents here. If you prefer our online application, submit this form, and we'll email you the necessary details promptly and there is no need to upload the application.

CAQH Number

Application & Documents Upload

I understand that this is just a request for an application to Join TIOPA. You will receive an email from the staff at TIOPA with your login link and credentials. You are responsible for the application to be submitted timely. If you have not received a link to your application within three (3) business days, please reach out to credentialing@tiopa.org.

PAYMENT

Please make sure to go on our website and pay the application fees. Your application will not be processed until payment is received.

Note: Annual dues are due every fall and reappointment fees are due every 3 years. Visit our TIOPA store more accurate fee amounts.

If you were referred to TIOPA by another provider, please let us know who below.

First NameLast Name

Signature