Clinician Intake Form
for Credentialing and Enrollment
Full Legal Name
Prefix
First Name
Middle Name
Last Name
Suffix
Organization Name
*
Enter the Org/Practice Name where you wil be practicing at
Degree (s)
*
Degree
Board Specialty
Practicing Specialty
Anticipated Start Date at this Organization
-
Month
-
Day
Year
Date
National Provider Identifier (NPI)
*
Date of Birth
*
-
Month
-
Day
Year
Date
Services Requested
*
Hospital Privileges
Payer Enrollment with Health Plans
State License Application
DEA Application
Will the Organization bill health plans for your services?
Yes
No
Engagement Status with the Organization
*
Employed W-2
Independent Contractor
Telemedicine
LOCUM Tenens
Your Role(s) in the Organization (select all that apply)
PCP
Specialist
Telehealth
Hospital Based
Clinic Based
Email
*
Enter email address where all communications for credentialing will be sent
Mobile Phone Number
*
Please enter a valid phone number.
Preferred method for contacting during credentialing related activities
*
Mobile Phone
Texting on mobile number
Email
CAQH Access Details
*
Validate Accuracy by logging www.CAQH.com, before submitting
Medicaid Portal Details
*
Validate accuracy by logging in to your Medicaid portal. Enter NA, if unknown
Current Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
List all States where you hold Active State Licenses
*
List all current DEA Licenses along with the States they are active in
*
Do you currently hold an active multi-state license?
Yes
NO
If Yes, List the States
Which state is your primary state of residence, if you hold multi-state license?
Are you aware of the practice location you will be providing patient care at?
If yes, enter the address here
Office Manager Full Name, Email and phone number
Comments:
If you have questions, please call 616-361-8292
Signature
Submit
Submit
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