Credentialing Intake — Superior RCM Solutions

Superior RCM Solutions

Provider Credentialing Intake

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Welcome!

This form is for providers who are new to Superior RCM Solutions and have not yet been credentialed. We use this information to build your credentialing file — the documentation payers and hospitals require before you can be enrolled and start billing.

If you have already been credentialed and just need to be enrolled with additional payers, please reach out to Andrea as you will need our Enrollment Intake form instead.

Before you start, have the following nearby: your CV, all state medical licenses, DEA registration, board certification, medical school diploma, current and (if applicable) previous malpractice insurance declarations pages, and two professional peer references.

This form saves your progress automatically as you go — feel free to complete it in more than one sitting. Fill out the sections below, upload your documents as you go, and submit when everything's ready.

All information submitted is kept strictly confidential and used solely for credentialing purposes in accordance with our HIPAA privacy practices.
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Provider Information

First, Middle, Last, Suffix — exactly as it appears on your state license
Please enter your legal name.
Select your primary credential type
Please select your credential.
Please enter your date of birth.
Your 10-digit individual NPI. Find it at npiregistry.cms.hhs.gov if needed. If you don't have one yet, leave blank and note that in Additional Notes.
Your numeric CAQH ProView ID, if you already have one. Leave blank if this is your first time creating a CAQH profile — we'll help you set one up.
Enter your primary specialty or billing taxonomy. Example: 101YM0800X
Please enter your primary specialty/taxonomy.
Used for credentialing correspondence only — not shared with payers
Please enter a valid email.
Please enter your mobile phone.

Practice/Group Information

Legal name of the practice or group. Solo providers use your legal name.
Please enter your practice or group name.
Only if billing under a group. Leave blank if solo practice billing under individual NPI.
Please enter your Tax ID.
Please indicate EIN or SSN.
Practice Address
Physical location where you see patients. Cannot be a P.O. Box.
Please enter the practice address.
Please enter the city.
Please enter the state.
Please enter the ZIP code.
Please enter the practice phone.
Please enter the practice fax.
Some payers/hospitals ask for availability. Example: Mon–Fri 9am–5pm

CV & Work History

Curriculum Vitae (CV) *

Your current CV.
Employment History — Last 10 Years
List your work history for the last ten years, if applicable. Use mm/yyyy format for start and end dates. If you're currently in this role, check "Current Position" instead of entering an end date.

Licensure

Add every state medical/professional license you currently hold, even states where you don't participate with insurance — payers and hospitals want your full licensure history. Upload a copy of each license.

Board Certification

Please select an option.

Education

Medical/Professional Education Diploma *

Diploma from the school that granted your primary professional degree.

DEA Registration

If applicable to your credential type (prescribers only) — leave blank if you do not hold a DEA registration.

DEA Certificate

Medicare/Medicaid Setup

The Medicare Provider Enrollment, Chain, and Ownership System.
Please select an option.
Please select an option.

PECOS/I&A Confirmation (optional)

If you have a confirmation letter or screenshot handy, upload it here.

Liability Insurance

Current Malpractice/Liability Insurance
Please enter your current carrier.
Please enter your policy number.
Please enter the effective date.
Please enter the expiration date.
Please enter your per-occurrence limit.
Please enter your aggregate limit.

Current Certificate of Insurance / Declarations Page *

Previous Malpractice/Liability Insurance
If applicable — leave blank if this is your first coverage.

Previous Certificate of Insurance / Declarations Page (optional)

Malpractice Claims History

Please select an option.

Hospital Affiliations

If applicable — list any hospitals where you hold privileges.

Peer References

Please provide at least two professional peer references who can speak to your clinical practice.

Billing Information

Please enter a billing contact name.
Please enter a billing contact phone.
Please enter a billing contact email.
Remit / Pay-To Address
Address where payers will send paper checks and correspondence. Leave checked if same as practice address.

Medical Records

Please enter a records contact name.
Please enter a records contact phone.
Please select an option.
Describe how long records are retained, e.g. "7 years past last encounter, per state requirements."
Please describe your records retention policy.

Attestation Questions

Answer each question honestly and completely. A "Yes" answer does not automatically disqualify you — it simply requires an explanation so we can address it as part of your credentialing file. Please use the explanation box for any answer that needs context.
1. Have you ever had your professional license, certification, or registration revoked, suspended, restricted, or placed on probation in any state? *
Please answer this question.
2. Have you ever voluntarily or involuntarily relinquished, limited, or failed to renew any professional license, DEA registration, or hospital/facility privileges while under investigation or in lieu of investigation? *
Please answer this question.
3. Have you ever been denied certification or recertification by a specialty board? *
Please answer this question.
4. Have you ever been convicted of, or pled guilty or no contest to, a felony? *
Please answer this question.
5. Have you ever been excluded, suspended, or debarred from participation in Medicare, Medicaid, or any other federal or state health care program? *
Please answer this question.
6. Do you have any physical or mental health condition that could affect your ability to perform the essential functions of your profession, with or without reasonable accommodation? *
Please answer this question.
7. Have you ever been the subject of a formal disciplinary action by a hospital, health plan, or professional society? *
Please answer this question.

Additional Notes

Signature

By typing your full legal name below and checking the attestation box, you are electronically signing this credentialing intake and confirming that everything you've entered is true and accurate to the best of your knowledge.
Please type your full legal name.
Please check the attestation box.
Your progress is saved automatically. You can close this page and come back to this same link anytime before submitting.

Provider Intake Data

Welcome! This form collects the information we need to begin your credentialing process. Credentialing is the verification of your professional qualifications with insurance payers — it is the required first step before enrollment and billing can begin.

Most providers complete this in about 20–25 minutes. Before you start, have the following nearby: your CAQH login, state license, malpractice declarations page, and CV — gathering these first makes the process much faster.

This intake has two parts. Complete the provider information form below and hit Submit — you will then be directed to the document upload form. Once your documents are uploaded, hit Submit a second time to finalize your intake. Both submissions are required before your credentialing work can begin.

If you are already credentialed and only need payer enrollment, please reach out to Andrea as you will need to complete the Enrollment Intake Form instead.

All information submitted is kept strictly confidential and used solely for credentialing and enrollment purposes in accordance with our HIPAA privacy practices.

Credentialing Document Upload

Use this form to upload all documents required for your credentialing. Documents are organized by category below. Upload all that apply — required documents are marked. Tip: scan all documents before starting and save them in one folder so uploading is quick. Documents must be current, legible, and complete. Missing documents will delay your credentialing timeline.