Get Draft Credentialing Request Form - Davitacom

Filling out the DRAFT Credentialing Request Form - Davitacom online is a straightforward process that helps facilitate your credentialing requests. This guide provides detailed, step-by-step instructions to ensure that you can complete the form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section I, provide your requestor information including your name, title, and email address. Ensure you enter the date you completed the form.
3. Proceed to Section II, where you will fill out the practitioner demographics. Include details such as first name, last name, middle name, and professional designation. If you are already credentialed with DaVita, skip to Section IV.
4. In Section II, complete the required fields like date of birth, social security number, gender, state license number, license expiration date, UPIN, NPI number, and practitioner email address. Note that some fields are mandatory for practitioners new to DaVita.
5. If applicable, provide your DEA number in this section.
6. Move to Section III, where you will input your practice information. Fill in the practice name, street address, city, phone number, state, fax number, and zip code.
7. In Section IV, handle facility requests by indicating whether you want to add or remove facilities from the practitioner's profile. Fill in the facility number, covering physician (if applicable), facility name, medical director, city, state, and the type of change requested.
8. Once you have completed all sections of the form, review your entries for accuracy. Finally, save your changes, download, print, or share the completed form as needed.

Complete your credentialing requests online with ease by filling out the DRAFT Credentialing Request Form - Davitacom today.