Credentialing Application Checklist

new provider information

credentialing application checklist.
personal information
full legal name*

First NameMiddle NameLast Name
email*
example@example.com
phone number*
Please enter a valid phone number.
date of birth*

MonthDayYear
social security number*
physical address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
professional information
highest degree*
E.g., Ph.D., Psy.D., M.A., M.S.
issuing institution*
license type*
license number*
effective date*

MonthDayYear
expiration date*

MonthDayYear
npi number*
Your unique 10-digit number
caqh / proview credentialing number*
required
medicare provider number
PTAN, if applicable
medicaid / medi-cal number
If applicable
are you currently in-network with any of these insurance panels?*

TricareSharp Health PlanAnthem / Blue CrossUnited Healthcare / Optum HealthAetna / First Health NetworkMedicareMagellan / Blue ShieldHealth NetCigna / EvernorthU.S. Behavioral Health PlanUnited Behavioral Health (UBH)University Health Alliance (UHA)None
supporting documentation
professional license*

Must be active in California
Cancelof
cv / resume*

Dates must include MONTH and YEAR and explain any gaps of 6 months or longer
Cancelof
highest degree diploma*

Cancelof
malpractice certificate

$1M/$3M requirements
Cancelof
drivers license or state issued identification card*

Cancelof
sample of your work

Please include REDACTED samples of your applicable clinical work
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professional references*

	Name	Relation	Phone	Email
Reference #1
Reference #2

I authorize Aloha Psych to use and verify all provided information for credentialing, in-network contracting, roster updates, and similar purposes. This includes submitting applications, updating professional records, and verifying my qualifications and references.

By signing, I consent to Aloha Psych's use of my information as described and confirm its accuracy.
signature*

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new provider information