Credentialing Client Intake Form

Purpose: The Credentialing Client Intake Form is completed and submitted by the new credentialing client after service agreement execution and payment, to capture the essential information needed to confirm project scope and initiate onboarding.

The Sales Department reviews the submission and shares it with the Credentialing Department as the formal project handoff, enabling the client to receive the applicable detailed Client Discovery Form from Credentialing Department to collect comprehensive practice/facility, provider, ownership, payer, service, billing and required documentation information.

Please complete all applicable fields. Fields marked with an (*) asterisk are required.

Section 1: Primary Client Contact & Organization Basics

Section 2: Business & Provider Identifiers

Section 3: Scope of Work

(Please refer to service agreement for actual payers and applications)

Section 4: Key Project Information

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 but not limited to 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 our credentialing services.

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

Despite the training provided, if the Client does not effectively use the ShareFile portal and fails or refuses to upload the required credentialing documentation within three (3) months of the initial onboarding date, the following shall apply:

  • TriumpHealth shall have no obligation to continue processing the credentialing services; and
  • The Client shall not be entitled to any refund or credit of amounts paid to TriumpHealth under this Agreement.

This provision is intended to ensure operational efficiency, data security, and adherence to TriumpHealth’s credentialing processes.

CAQH or ADA Access

If the Client is not willing or able to provide access to provider’s existing (CAQH Council for Affordable Quality Healthcare) or ADA (American Dental Association) profile, then TriumpHealth is not liable for any credentialing application denials or removal of provider from the network panel due to incomplete profile 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 the failure to disclose the exact type of physical location can result in delays, denials, enrollment rejections, site visit failures, or sanctions resulting from inaccurate, incomplete, or non-compliant information provided.

Pricing Terms

The pricing set forth in the Agreement you signed with Triumphealth is contingent upon the Client’s adherence to the use of 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.

Please fill and sign below to confirm that all information you completed above is true and correct, and that you have reviewed and agree with the “NOTES” section above.

Client Certification & Signature

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