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.