(click on file name for download)
Physician Initial Application (Part 1).doc
(size: 620.0 KB last modified: 03-03-2007 )
Physcian (MD/DO, DDS/DMD) Initial Appointment
(with NPI field)
Physician Initial Application (Part 2).doc
(size: 348.7 KB last modified: 03-03-2007 )
Physcian (MD/DO, DDS/DMD) - Additional application information.
(for Managed Care Organizations)
Physician Recredentialing Reappointment.doc
(size: 275.5 KB last modified: 03-03-2007 )
Physcian (MD/DO, DDS/DMD) Recredentialing / Reappointment Application.
(with NPI field)
AHP Initial Application (Part 1).doc
(size: 526.8 KB last modified: 03-03-2007 )
ALLIED Healthcare Practitioner (PhD, CRNA, PA, etc.) Initial Application
(with NPI field)
AHP Initial Application (Part 2).doc
(size: 173.6 KB last modified: 03-03-2007 )
ALLIED Healthcare Practitioner (PhD, CRNA, PA, etc.)
Additional application information - (for Managed Care Organizations)
AHP Initial Application (Part 2) - Additional Practice.doc
(size: 95.2 KB last modified: 08-21-2008 )
Part of Application - Avalable for download as a "stand alone" document.
(additional copy)
AHP Recredentialing Reappointment.doc
(size: 276.5 KB last modified: 03-03-2007 )
ALLIED Healthcare Practitioner (PhD, CRNA, PA, etc.) Recredentialing Application
(with NPI field)
Schedule A.doc
(size: 47.6 KB last modified: 03-03-2007 )
Part of Application - Available for download as a "stand alone" document.
(additional copy)
Schedule B.doc
(size: 68.1 KB last modified: 03-03-2007 )
Part of Application - Available for download as a "stand alone" document.
(additional copy)
Schedule C.doc
(size: 58.9 KB last modified: 03-03-2007 )
Part of Application - Available for download as a "stand alone" document.
(additional copy)

Admin

PLEASE NOTE:

Keep a copy of your original application, either saved on your computer or a hard copy for future use.

Maintain the form(s) by updating with new information as needed.

Every time you are credentialed, the Hospital, Health Plan and/or other Healthcare Entity(ies) will require your signature and date on a new "Authorization and Signature" page. This form allows the plan or hospital to verify the information you've included on your application by confirming it from primary sources. It also contains an attestation stating that the information on your application is current and true to the best of your knowledge.

Please review each copy of the application form prior to submitting to ensure that all sections are complete (incomplete forms will not be accepted!). Remember, in order for your application to be considered complete, you must submit Part One & Part Two simultaneously.Please insert your text here.