Get Champva Provider Credentialing Form

Filling out the Champva Provider Credentialing Form accurately is essential for providers seeking to start or maintain their participation with the Champva program. This guide will provide you with clear instructions to help you complete the form effectively.

Follow the steps to complete the Champva Provider Credentialing Form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Begin with Section I, Provider Identification. Here, provide the legal business name as reported to the IRS and the 'doing business as' name, if applicable. Additionally, include the address, county, and tax identification number.
3. Move to the Current Practice Locations section. Document the practice location name and address, including city, state, and zip code. Ensure to provide a contact name, phone number, and email for correspondence.
4. In Section D, Type of Provider, select the appropriate provider types that apply to your organization by checking all applicable boxes.
5. Continue to the Scope of Services section, where you will list all services your facility provides. Ensure to be comprehensive in your descriptions.
6. Section II requires you to provide details regarding certification and accreditation. Indicate whether your facility participates in the Medicare program and provide relevant dates and information as requested.
7. Provide necessary health care licensure and registration details in Section III. Fill out all relevant numbers and issue dates for licenses held.
8. In Section IV, Liability Insurance, include details about your current coverage, such as carrier name, policy number, coverage type, and amounts.
9. Proceed to Section V and indicate if your facility has a formal credentialing program in place for healthcare professionals.
10. For sections VI and VII, confirm if you have policies regarding patient visitation and restraint/seclusion procedures. If yes, provide additional documentation as needed.
11. In Section VIII, ensure to include all required attachments as specified, such as copies of licenses and accreditation documents.
12. Once all sections are completed, ensure to review for accuracy and completeness. Sign and date the application as required.
13. After finalizing the form, save your changes, then download, print, or share your completed application as necessary.

Start completing the Champva Provider Credentialing Form online today to ensure your application is processed efficiently.