Get Credentialing Initiation Form - Centerpoint Human Services - Cphs

Completing the Credentialing Initiation Form for CenterPoint Human Services is a crucial step for practitioners to ensure their services can be billed appropriately. This guide provides structured, step-by-step instructions to navigate through the online form with ease and accuracy.

Follow the steps to successfully complete the Credentialing Initiation Form.

1. Press the ‘Get Form’ button to access the form and open it for completion.
2. Fill in your name by entering your first, middle, and last name without using initials. If you do not have a middle name, input 'NMN'. Include any applicable suffix such as Jr., Sr., or III.
3. Enter the name of your practice associated with this credentialing application. This could be your name if you operate a solo practice or the name of a group practice, agency, or hospital.
4. Select your provider type from the list provided, which includes options such as MD, DO, PA, NP, Clinical Psychologist, Professional Counselor, and others. Remember that provisionally licensed practitioners can apply only if they are employed by an agency.
5. Input your preferred email address for credentialing correspondence, as this will be the primary method of communication.
6. Provide a telephone number that will be used for credentialing purposes.
7. Enter your date of birth in the specified format: two-digit month, two-digit day, and four-digit year.
8. Fill in your mailing address where you wish to receive credentialing communications.
9. Complete the practice information section relative to your business entity that will bill for services.
10. If you are a provisionally licensed independent practitioner, attach a copy of your supervision contract along with your supervisor's contact information. Include an attestation from your clinical supervisor.
11. Print two copies of the Provider Reference Form. Ensure one reference comes from a likelicensed practitioner, and if provisionally licensed, one must be from your clinical supervisor. Have the references submit the forms to CenterPoint Human Services.
12. If there are any employment gaps exceeding six months, provide a brief explanation.
13. Indicate that you have professional liability insurance with coverage of $1 million per occurrence and $3 million in the aggregate.
14. Indicate whether your office is accessible to individuals with disabilities. If not, provide information on how you plan to accommodate.
15. Sign and date the form where indicated to confirm that the information provided is accurate.
16. Complete the ownership, managing employees and electronic funds transfer section if applicable. Following this, disclose any 5% ownership or control interest in organizations billing Medicaid.
17. Once all fields are completed, save your changes, download the form, print it, or share it as needed.

Complete your Credentialing Initiation Form online today to ensure a smooth credentialing process.