Get Credentialing Form For Non-physicians.

Completing the Credentialing Form For Non-physicians can feel overwhelming, but it is an essential step for practitioners seeking credentialing services. This guide will provide you with clear, step-by-step instructions to assist you in accurately filling out the form online.

Follow the steps to effectively complete your Credentialing Form.

1. Click the ‘Get Form’ button to access the Credentialing Form For Non-physicians. Ensure that the form opens in your preferred digital editor.
2. Begin by filling out the section related to your source of information about WCH credentialing services. Choose one option from the list provided: postcard, website, referral, returned client, or other, and fill in the blank if necessary.
3. Enter your full name in the format of first name, middle name (if applicable), last name, and degree. Ensure the spelling is accurate to prevent processing delays.
4. Fill out your client contact information, including your home address, city, state, and zip code. Provide your cell number and email for further communication.
5. Input your CAQH ID along with its user ID and password, if applicable. Also, fill in your PECOS user ID and password.
6. Indicate your date of birth, and the city and country of your birth.
7. Provide your professional data, including state license number, Social Security number, NPI number, DEA number, Medicare number, Medicaid number, and CDS number.
8. List your primary specialty and indicate whether you are board certified or board eligible. Provide the name of the certifying board and dates of certification and expiration.
9. If applicable, specify your sub-specialty along with similar certification details as in the previous step.
10. Indicate any age limitations by checking the appropriate response (yes or no) and providing the specific minimum and maximum ages, if necessary.
11. State whether you currently have hospital admitting privileges. If applicable, include the name and address of the hospital.
12. Complete the covering provider information section, ensuring that names and addresses of covering providers are filled out correctly. Input specialties for each provider.
13. For the practice information section, include all relevant details for your service locations, including business name, group NPI, tax ID, and contact information.
14. Fill out billing information with details on who checks should be made payable to, along with an address and contact information.
15. If different from the billing address, specify the correspondence information where the insurance company can contact you.
16. Be sure to attach copies of all required documents, such as state license, CV, medical liability insurance coverage, IRS Form W-9, and any relevant certifications.
17. Handle the confidential information questions. Carefully answer each question regarding malpractice history and provide explanations where needed.
18. Complete the form by providing your signature and date. Review all your entries for accuracy before final actions.
19. Once everything is filled out, save your changes. You may then download, print, or share the completed form as per your requirement.

Start completing your documents online to ensure a smooth credentialing process.