Provider Intake Form

Provider Intake Form
Name

First NameLast Name
Email Address
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
SSN or Tax ID Number
NPI Number
CAQH ID & Login credentials
State License Number & Exp Date
Primary Specialty
Subspecialty (if applicable)
Group / Practice Name
Group / Practice Tax ID Number
Group / Practice NPI Number
Practice Contact Name

First NameLast Name
Practice Contact Number
Please enter a valid phone number.
Billing Contact Name (if different)

First NameLast Name
Billing Contact Phone Number (if different)
Please enter a valid phone number.
Effective Date with Group

MonthDayYear
Date
Office / Practice Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Practice Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List of insurance plans to credential or enroll with
Are you re-credentialing or new enrollment?
Is this a solo or group contract?
Additional notes or special instructions
State license copy

Cancelof
Board certification

Cancelof
Malpractice insurance face sheet

Cancelof
W-9 form

Cancelof
Driver’s license

Cancelof
CV (with at least 10 years of work history, month/yearformat)

Cancelof
I hereby certify that the information provided in this intake form is true and accurate to the best of my knowledge. I authorize EmpowHer Credentialing to act on my behalf to complete and submit credentialing, enrollment, and re-credentialing applications to health plans, networks, and applicable organizations.I understand that EmpowHer Credentialing may contact me for additional documentation or clarification as needed.

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Date Signed

MonthDayYear
Date
Should be Empty: