Get Physician And Mid-level Credentialing Application - Educators Mutual

Filling out the Physician And Mid-level Credentialing Application - Educators Mutual is an essential step for healthcare professionals seeking to join a network with this organization. This guide offers clear, step-by-step instructions to help you navigate the application process with ease and confidence.

Follow the steps to complete the application accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your editing tool.
2. Begin filling out your personal information. This includes your last name, first name, middle initial, and social security number. Ensure all entries are correct to prevent processing delays.
3. Provide details about your practice, including clinic or office name and both NPI numbers if applicable. Be sure to check the correct box for billing information.
4. Complete the address sections, including principal and secondary office locations. Fill in the street address, city, state, zip code, and county for each location.
5. Input your telephone number and other contact details, including fax numbers and email addresses.
6. Fill in the billing address and correspondence address if different from the primary office location. Include relevant contact names and telephone numbers.
7. Provide information regarding your medical licensure including your primary and secondary state of licensure, license numbers, and any applicable copies of documentation.
8. Indicate your hospital affiliations by checking the appropriate boxes for primary and other hospital affiliations, providing locations as needed.
9. List your board certifications and specialties. Indicate whether you are board certified or eligible for board certification, and provide certifying board names and exam dates.
10. Complete the education section by entering the details of your medical school, internship, residency, and any fellowships.
11. Answer questions regarding your practice, including whether you have partners, employ other medical staff, and any past suspensions or limitations to your practice.
12. Provide details of any malpractice actions and attach necessary documentation as specified in the application.
13. Attach required enclosures, such as copies of licenses, insurance proof, board certifications, and any other documentation requested.
14. Review all information for accuracy and completeness before signing the application to confirm validity.
15. Save your changes, and download or print the completed application for submission.

Complete the credentialing process online today by carefully following these instructions.