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Filling out the Credentialing Application online is a straightforward process. This guide will provide step-by-step instructions to help users efficiently complete the required information and submit the form correctly.

Follow the steps to successfully complete the Online Credentialing Application.

1. Press the ‘Get Form’ button to access the application form and open it in your browser.
2. Begin by filling out the provider and office information section. Input your last name, first name, degree (DDS or DMD), date of birth, and Federal Tax ID number. Remember to attach your W-9 form if applicable.
3. Complete the billing name, middle initial, gender, provider NPI number, and provider social security number. Enter the office street address, suite number, city, state, and ZIP code.
4. Provide the office phone number, fax number, website, and email address. Specify the office hours for each day of the week and the minimum and maximum ages of patients accepted.
5. Indicate the languages spoken and provide information on your educational background, including the name of the dental school, state, and year of graduation.
6. Detail your dental specialty and the name of the institution for any residency or specialty training. Fill out your state license number, Medicaid number if applicable, and your DEA registration number.
7. List your work history for the past five years and provide explanations for any gaps in employment. Include start and end dates along with the places of employment.
8. Answer all questions in the professional liability section accurately. If any responses are 'yes', provide documented explanations.
9. Complete and sign the consent and release form, ensuring all information is accurate, then verify all fields are complete.
10. Finally, save your changes, then download or print the application for your records before sharing it with the appropriate address or email.

Complete your Credentialing Application online today for a smoother process.