Client Intake Form

SECTION 2: CONTACT INFORMATION

Primary Contact Name * Primary Contact Title * Primary Phone * Primary Email * Secondary Contact Name Secondary Contact Title Secondary Phone Secondary Email Physical Address * Billing Address * Mailing Address * Business Phone * Business Fax Preferred Contact Method * -- Select -- Phone Email Best Time to Contact * Back Next

SECTION 3: PRACTICE IDENTIFIERS

Group NPI * Group Medicare PTAN * Group Medicaid ID * Tax ID (EIN) * Multiple TINs Used? * -- Select -- Yes No CAQH Account Number CAQH Username / Email Revalidation Due Dates Known? * -- Select -- Yes No Participating in PECOS? * -- Select -- Yes No Back Next

SECTION 4: OWNERSHIP INFORMATION

Owner Name(s) * Ownership % * Ownership Type * -- Select -- Individual Partnership Corporate Primary Contact for Ownership Documents * Back Next

SECTION 5: PROVIDER DETAILS

Provider Name * Degree/Credentials * Individual NPI * Specialty/Subspecialty * Previously Credentialed? * -- Select -- Yes No Medicare/Medicaid refused or Terminated? * -- Select -- Yes No If Yes, Please Explain Current Sanctions / Legal Issues? * -- Select -- Yes No Licensure State(s) * License Number & Expiration * DEA Number Board Certification? * -- Select -- Yes No Back Next

SECTION 6: SERVICES RENDERED

Describe Services Offered * Service Delivery Type * -- Select -- In-Person Telehealth Hybrid Patient Demographics Served * -- Select -- Pediatrics Adults Geriatrics All Ages Facility/Location Type * -- Select -- Clinic Hospital Private Practice Mobile Unit Telemedicine Only Average Monthly Patient Volume * Back Next

SECTION 7: SCOPE OF WORK

Requested Credentialing / Enrollment Services * Preferred Start Date * Urgency Level * -- Select -- Normal High Priority Urgent Special Instructions / Notes Back Next

SECTION 8: DOCUMENT UPLOADS & ACKNOWLEDGMENT

Upload your documents securely:

License (Required) W9 (Required) CV (Required) Malpractice Insurance DEA Certificate Board Certification Document

Authorization

Name (Signature) * Date of Signature * Additional Comments / Notes Back Submit