Credentialing Information Sheet Facility Group Indivisual Status Onbording Initial Appointment Re-Appointment CAQH Maintenance Demographics Update Date of Request: Full Legal Name Any Previous Names Date of Birth MM DD YYYY Gender Male Female SSN TIN NPI Place of Birth Citizenship Physical Address City, State, Zip: Provider Type List all Credentials Office Phone / Home Phone Mobile phone: Email Active Military Yes No Branch of Service Facility/Group NPI (if working for a practice or organization): Facility/Group TIN (if working for a practice or organization and you will bill under them): Current/Last Medical Work History: (address, email, phone number and provide dates) Education – Post Grad: (address, email, phone number, date of grad.) Any claims, malpractice, suspensions, limitations, board action against you or pending? Please explain MD License No. / Exp. And State Medicare No./PTAN and State: DEA No. / Exp. And State, if prescribing. N/A if no DEA if you are an NP or PA. MD’s are required to have a DEA. You must have a DEA registration for each state you can prescribe in. UPIN Primary Specialty Secondary Specialty Insurance Co. Phone #: Exp. Date: Policy #: CAQH Login: # User Name: Password: List additional state licenses Medicaid No. and State: Board Certified – list which board Government Issue identification - Please provide a government issued ID (State Driver’s License, Passport) Please indicate what panels (insurance companies) you wish to be in-network and contracted with? BCBS/Anthem/Empire/Tufts Humana/Humana Tricare Cigna Aetna UBH, United Healthcare, Optum Medicare Medicaid (all CVO’s, Marketplace) Other Specify Primary Billing Office Address City, State, Zip City, State, Zip Phone Number Country (###) ### #### Fax Credentialing Contact/Office Manager Name Address Phone Number Country (###) ### #### Fax Type of Practice Practice Name Populations Served Days/Hours of Operation Any additional comments Thank you!
