Credentialing Intake Form Please provide as much information as possible. Fields marked with * are required. 1Practitioner Information2Practice Information3Documents Upload Practitioner InformationPractitioner Legal Name* First Middle Last Title Practitioner Email*Enter email to use for credentialing correspondence Enter Email Confirm Email Personal Phone Number*To be used to contact provider directly. What should we call you? (Optional Nickname) Nickname Preferred Pronouns*We want to communicate with you in an authentic way and acknowledge your given identity, please select how you would like us to interact with you: They/Them She/Her He/Him Do you consent to have this information given to insurance carriers for the purpose of identifying you in their internal processes as well as on their websites?*Please note: Not all insurance carriers will have all selections or list gender. Yes No Date of Birth* MM slash DD slash YYYY Specialty*Acupuncturist (LAc, MAOM, DOM, etc.)Massage Therapist (LMT)Behavioral Health (LPC, MFT, LCSW, PsyD, etc.)Registered Dietician (RD)Naturopath (ND)Chiropractor (DC)Physical Therapist (PT)Occupational Therapist (OT)State License Number* Personal NPI Number (Type 1)* CAQH Account (ProView) - User NameIf you have a CAQH ProView account, please enter below. If you do not have one, leave blank and we will generate one for you. Please note that ProView (proview.caqh.org) is different than other CAQH accounts. CAQH Account (ProView) - Password Social Security Number* Practice InformationName of Primary Clinic/Practice* Clinic Tax ID Number*This is the number you will use on your W-9 for business tax purposes. Federal Tax Classification*As registered with the IRS and listed on W-9 form. Individual/Sole Proprietor or Single Member LLC C Corporation S Corporation Partnership LLC - C Corporation LLC - S Corporation LLC - Partnership Other I don't know Organizational NPI Number (Type 2)Note: This is not the same as personal NPI. Checks Payable-to Name* Practice Start DateDate you were hired/began seeing patients at this location. MM slash DD slash YYYY Is Practice located in your residence/home?* No Yes Primary Practice Address* Street Address (Include Apt, Room, or Suite #) City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code + 4 digits Name of County or Counties you serve:* Billing Address (Must match W-9)* Street Address (Include Apt, Room, or Suite) City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP code + 4 digits Patient Appt Phone*This number will be used by patients to make appointments, & for websites and directories.Clinic/Office Fax Number (Please include!)Clinic/Office Email* Enter Email Confirm Email Clinic Website List secondary or tertiary practice location(s) information here. Only include if you are credentialing more than one clinic. (Address, Tax ID Number, Patient Appt Phone Number, Fax, Email, & Organizational NPI, if applicable.) Select NetworksInsurance Companies*Please list any insurance companies that you would like to apply for. Please note that not all plans are available in all areas. We will do our best to get you what you want, but it's not always possible. If you're not sure what you want or would like a list to look over, write in"Let's Talk" and we will contact you for a discussion.
