Get Trillium Health Resources Credentialing Application To Participate As A Health Care Provider 2021-2025

Filling out the Trillium Health Resources Credentialing Application requires careful attention to detail to ensure all necessary information is provided accurately. This guide offers comprehensive, step-by-step instructions to assist you in completing the application efficiently and correctly.

Follow the steps to fill out your application successfully.

1. Click the ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by reviewing the general instructions on the first page of the application to understand the requirements for submission.
3. In Section 1: Corporate Information, provide your organization’s legal name, federal tax ID number, NPI number, organization address, and contact information. Ensure every field is completed or marked as 'N/A' where applicable.
4. Move to Section 2: Ownership Information. List all individuals who hold a 5% or more ownership stake in the organization and include their title, address, date of birth, social security number, and license number.
5. In Section 3: Site Specific Information, detail each service site where services will be provided, including the address, phone number, and services rendered. This section may need to be duplicated if there are multiple sites.
6. Section 4 requires you to list all licensed practitioners involved in care provision. Ensure you include their taxonomy number and license type.
7. Complete the attestation statement at the end of the application, confirming the accuracy of your submission. The designated individual should print their name, sign, and date the statement.
8. Gather required supporting documentation, including insurance certificates and compliance attestations. Ensure all documents are in the specified order as mentioned in the instructions.
9. After filling out the application and gathering all necessary documentation, save your changes. You may choose to download, print, or share the completed form as needed before submission.

Complete your application online today to ensure timely processing of your credentialing request.