Providers Credentialing Submission Request Providers Credentialing Submission Request Submit a Practitioner for Credentialing You must have JavaScript enabled to use this form. Add Provider for Credentialing For new practitioners with your practice, please fill out the required information. For multiple practitioner submissions, please download the template with the required information and attach to the form. Practitioner Information First Name * Middle Initial Last Name * Date of Birth * Practitioner Gender - None -FemaleMaleNon-BinaryUnknown Practitioner Title CAQH Provider ID * National Provider Identifier (NPI) * Practitioner’s specialty * Effective Date with Practice * Group Details Group Tax ID * Group NPI * Primary Location (if applicable) Primary Practice Location Address * Address 2 City/Town * State/Province * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code * Secondary Location (if applicable) secondary_location Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Is the provider associated with a previous group? Was Provider a part of a Previous Group? Yes No Previous Group Name Provider is still active with previous group? Yes No Termination Date Credentialing Contact Details Contact Name * Contact Phone Contact Email * Attach a Practitioner Roster For multiple practitioner submissions, please download the template with the required information and attach to the form. Attach a Practitioner Roster Unlimited number of files can be uploaded to this field.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, xls, xlsx, xml, zip. Leave this field blank
