Client Discovery Form

Privacy, Confidentiality, and Security of Credentialing Documents

To maintain compliance with HIPAA and to safeguard Client privacy, confidentiality, and data security, TriumpHealth strictly prohibits the transmission of credentialing documents, including licenses, DEA certificates, IRS forms, and other personal information or sensitive documents, via email, postal mail, or fax.

Technology Platform Usage Requirements

All credentialing documents required to complete the credentialing process must be uploaded directly by the Client to TriumpHealth’s HIPAA-compliant ShareFile portal during the onboarding process. Failure to comply with this process may result in delays or inability to proceed with credentialing services.

If the Client is unable to navigate or upload the required documentation through ShareFile after initial onboarding and workflow training, TriumpHealth will provide one additional training session at no additional cost.

If the Client does not effectively use the ShareFile portal and fails or refuses to upload required credentialing documentation within three (3) months of the initial onboarding date, TriumpHealth shall have no obligation to continue processing credentialing services and the Client shall not be entitled to any refund or credit of amounts paid under the Agreement.

CAQH or ADA Access

If the Client is not willing or able to provide access to a provider’s existing CAQH Council for Affordable Quality Healthcare or ADA American Dental Association profile, TriumpHealth is not liable for credentialing application denials or removal of a provider from a network panel due to incomplete profile information and/or lack of attestation.

Primary Location Address

I verify that the primary location address provided above is not a virtual office, mail drop, P.O. Box, mailbox service, or other address that fails to meet the enrollment requirements of any payer. I understand that inaccurate or incomplete physical-location information may result in delays, denials, enrollment rejections, site visit failures, or sanctions.

Pricing Terms

The pricing set forth in the Agreement signed with TriumpHealth is contingent upon the Client’s adherence to TriumpHealth-recommended technology platforms and workflows, including the ShareFile portal process.

Scope of Work Precedence

In the event of any conflict, inconsistency, or discrepancy between the Scope of Work set forth in the executed Service Agreement and any project-scope information provided in the Client Intake Form, the terms of the executed Service Agreement shall control and be deemed final and binding.

I certify that the information provided in this form is true, complete, and accurate to the best of my knowledge. I authorize use of this information for payer enrollment, credentialing and compliance assessment. Completion does not guarantee payer approval, network participation, contract acceptance, reimbursement, or effective dates.