Get Practitioner Credentialing Application Packet - Providers

Navigating the Practitioner Credentialing Application Packet can seem daunting, but this guide is designed to help you fill it out with confidence. By following these clear, step-by-step instructions, you will ensure that your application is complete and ready for submission.

Follow the steps to effectively complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information in Section A. This includes your legal/professional name, date of birth, gender, social security number, and contact details. Ensure all fields are completed accurately.
3. Move to Section B to provide details regarding your board certifications. You will need to indicate your certification specialties, including expiration and recertification dates.
4. Fill out Section C about your professional licensure. List all active and inactive licenses, including their numbers, issuing states, and expiration dates.
5. In Section D, include any controlled substances certifications you hold. Provide information for Hawaii CSC and Federal DEA certificates if applicable.
6. Detail your professional liability insurance coverage in Section E. Include information on the providers, policy numbers, coverage amounts, and effective dates.
7. Section F requires information about your professional education and training. List your educational institutions, degrees earned, and completion dates.
8. In Section G, provide hospital affiliations and privileges. Include details about your admitting privileges and any necessary supporting documents.
9. Document your work history for the last five years in Section H. If there are gaps longer than six months, explain them in the designated area.
10. Section I involves confirming your completion of the Med-QUEST registration. Indicate your Medicaid ID status and upload any supporting documentation.
11. Review and complete the cultural competency and nondiscrimination sections in Sections J and K, providing necessary confirmations.
12. Lastly, complete the attestation section at the end of the form to affirm that you have provided accurate information.
13. After completing all sections, save your changes, download or print the form for your records, and share it as needed for submission.

Complete your Practitioner Credentialing Application Packet online today to ensure timely processing and approval!