Credentialing Client Discovery Form

This form focuses on gathering information on the wound care providers, practice, services offered, location, documentation, and payer details needed to assess Medicare/Medicaid, Medicare Advantage, Medicaid MCO and commercial payers credentialing and enrollment requirements.

• Complete every applicable field. Select only services currently provided or planned.

• Upload supporting documents through the secure upload fields. Do not email protected or sensitive documents.

• Items marked “if applicable” may not apply to every provider or practice. Upload documentation through the secure portal only.

• Submission does not guarantee payer approval, network participation, or reimbursement.