Get Sfdph Online Credentialing Verification Form

This guide provides users with clear and concise instructions on how to accurately fill out the Sfdph Online Credentialing Verification Form. With user-friendly steps, this resource aims to support everyone in the process of credentialing and verification.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Review the ‘New Staff ID’ section. If you are submitting a new request, check the box labeled ‘New’ and ensure all personal information is filled out legibly, including your last name, first name, middle initial, suffix, and Social Security Number.
3. Complete the ‘DOB’ (date of birth) and gender fields in the Personal Information box to ensure all vital details are captured.
4. In the Program Information box, select the applicable program type and provide the program name, RU/program code, street address, city, state, zip code, agency phone, and agency fax numbers.
5. Fill out the License/Certification Information box with your degree, license type, license number, state issued, expiration date, DEA number, Medi-Cal PIN, Medicare PTAN, NPI number, and taxonomy code as appropriate.
6. In the Signatures and Contact Information box, ensure both the employee and supervisor provide their signatures, along with the date, phone number, and email addresses, as these are mandatory for processing.
7. Indicate any additional staff who need to be notified of the employee's Staff ID number by filling in their names and email addresses.
8. After completing all sections, fax this form directly to the Avatar Accounts Manager at (415) 255-3008.
9. For any updates, repeat steps 1 to 8, checking appropriate boxes for updates needed, and fax the form to the DPH Compliance Office at (415) 252-3032.
10. If the staff is non-licensed, ensure to fill out the Attestation for Non-Licensed Staff and MAA Billing form, obtaining the supervisor’s signature, and include it with the first page.

Complete your Sfdph Online Credentialing Verification Form online today to ensure timely processing.