Credentialing Intake Application

SECTION 3: CREDENTIALING REQUEST TYPE
Individual Provider CredentialingGroup Practice CredentialingAdding Providers to Existing GroupNot sure - need guidance
SECTION 4: PRACTICE INFORMATION
Legal Business Name*
DBA (if applicable)
Tax-ID*
Organization NPI (Type 2)*
Group Taxonomy Code (if available)
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telehealth OnlyIn-PersonHybrid
Practice Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Practice Email*
example@example.com
Practice Website (if available)

PROVIDER DETAILS

Please add all provider(s) who will be added to the group.
Name*

First NameLast Name
Credentials (LCSW, LPC, LMFT, Psychologist, Psychiatrist)*
Individual NPI (Type1)*
CAQH ID*
State(s) Licensed In*
License Number*
License Expiration Date*

MonthDayYear
Date
Provider Email*
example@example.com
Provider Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

PROVIDER DETAILS cont.

Please add all provider(s) who will be added to the group.
Name

First NameLast Name
Credentials (LCSW, LPC, LMFT, Psychologist, Psychiatrist)
Individual NPI (Type1)
CAQH ID
State(s) Licensed In
License Number
License Expiration Date

MonthDayYear
Date
Provider Email
example@example.com
Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

SECTION 9: PRACTICE SERVICES
Mental Health TherapyPsychiatryBehavioral Health ServicesCoaching / ConsultingSubstance Use TreatmentOther
In-Person ServicesTelehealth ServicesBoth

Section 8: Consultation Expectations
I understand this consultation is an assessment to determine scope, pricing, and enrollment strategy*
I understand approval is determine by the insurance carrier*
I authorize Divine Billing & Credentialing Services to communicate with the insurance companies and assist with the submission of credentialing and payer enrollment applications on behalf of my practice. *
Date*

MonthDayYear
Date
Should be Empty:

SECTION 1: CREDENTIALING READINESS