INSURANCE CREDENTIALING FORM
Provider Name*
First Name Middle Name Last Name Suffix
Title*
Provider SSN#:*
Provider DOB:*
Month Day Year
Date
Federal Tax ID:*
Business Name*
Name as it appears on IRS Letter
Phone Number*
Area Code Phone Number
Fax Number*
Area Code Phone Number
E-mail:*

Confirmation Email name@example.com
Provider Address:*
Street Address
Street Address Line 2
City State
Zip Code
Mailing Address Same As Provider Address:*
Yes No
Provider Mailing Address:*
Street Address
Street Address Line 2
City State
Zip Code
Individual NPI:*

Confirmation Email
Group NPI:*

Confirmation Email
Group Medicaid ID:*

Confirmation Email
Individual Medicaid ID:*

Confirmation Email
Group Taxonomy:*

Confirmation Email
Individual Taxonomy:*

Confirmation Email
Group Medicare PTAN:*

Confirmation Email
Individual Medicare PTAN:*

Confirmation Email
CAQH*
CAQH Login:*
CAQH Password:*
Required Documents:*
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INSURANCE CREDENTIALING FORM