Provider Intake Form
Name
First Name
Last Name
Email Address
example@example.com
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
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 Name
Last Name
Practice Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Contact Name (if different)
First Name
Last Name
Billing Contact Phone Number (if different)
Please enter a valid phone number.
Format: (000) 000-0000.
Effective Date with Group
-
Month
-
Day
Year
Date
Office / Practice Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Practice Location
Street Address
Street Address Line 2
City
State / 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
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Board certification
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Malpractice insurance face sheet
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W-9 form
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Driver’s license
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CV (with at least 10 years of work history, month/yearformat)
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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.
Date Signed
-
Month
-
Day
Year
Date
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