Get Request For Credentialing Application (to Credentialing ... - Pacificare

Filling out the Request For Credentialing Application is a crucial step in the credentialing process for healthcare providers. This guide will help you navigate through each section of the application to ensure you complete it accurately and efficiently.

Follow the steps to complete the credentialing application online.

1. Press the ‘Get Form’ button to access the credentialing application and open it in your preferred document editor.
2. Begin by filling out the identifying information section. You will need to provide your last name, first name, degree, middle name, Social Security number, tax identification number, UPIN, DEA number, malpractice insurance number, Medicare number, and Arizona license number. Ensure that all fields are accurate.
3. In this section, you must also provide your date of birth and select your gender. Additionally, indicate your contracted specialty type, and provide details about your residency, including whether it has been completed and the date of completion.
4. You must also provide information regarding your hospital privileges and board certification status. If applicable, indicate the language(s) you speak.
5. Address the question about probation status with any licensing entity. Select 'Yes' or 'No' accordingly, remembering that being on probation disqualifies you from applying for PacifiCare credentials.
6. Continue to the practice information section. If you are part of a practice, provide the practice name and the names of other physicians in the group. Fill out the mailing address for the credentialing application and include your city, telephone number, and fax number.
7. Provide the name and contact number of the office manager or credentialing contact, along with the primary office street address if it differs from the mailing address.
8. For internal use, fill out the proposed networks and contract intentions. Indicate whether this is an individual contract or an addition to an existing contract, and provide the intended contract effective date and fee schedule or contract pricing if available.
9. Finally, ensure that all information is accurate and complete. Save the changes to your document, and you can either download, print, or share it for submission.

Complete your application online today to move forward in the credentialing process.