Credentialing Client Discovery Form
(Mental & Behavioral Health Provider/Group Credentialing)
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.
Thank You!
Your Mental & Behavioral Health Credentialing Discovery Form has been submitted successfully.
Our credentialing team will review the information and contact you if clarification or additional documentation is required.
Organization: —
Secure document reminder: Do not email sensitive credentialing documents. Use the approved HIPAA-compliant secure upload process.
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