Credentialing Client Discovery Form (Orofacial Pain & Dental Sleep Medicine)

Credentialing Client Discovery Form

(Orofacial Pain & Dental Sleep Medicine)

Purpose: This form collects provider, practice, services, locations, devices/lab relationships, payer, documentation, and compliance details needed to assess credentialing, contracting, payer enrollment, and related requirements for Orofacial Pain and Dental Sleep Medicine providers.

Instructions:

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

• Items marked “if applicable” may not apply to every provider or practice.

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

• Use the notes fields for payer-specific concerns, clinical workflow details, billing questions, or enrollment barriers.

• Completion does not guarantee payer approval, network participation, contract acceptance, reimbursement, or claim payment.

Section 1 - Primary Client Contact & Practice / Entity Information

Primary Practice Address

Mailing Address

State(s) of Operation *

Primary Specialty / Service Focus *

Practice Setting *

Section 2 - Key Identifiers

Section 3 - Ownership, Management & Administrative Structure

Section 4 - Scope of Work

The selected scope must match the signed service agreement.

Requested Credentialing / Enrollment / Setup Services

State(s) for Enrollment *

Section 7 - Orofacial Pain & Dental Sleep Medicine Services Offered

A. Orofacial Pain Services

B. Dental Sleep Medicine Services

Section 8 - Patient Population, Referral Sources & Care Model

Age Range

Referral Sources

Telehealth Used For

Sections 6 & 11 - Provider Type, Credentials & Enrollment Roster

Complete one row per clinician/provider. You may also attach an additional provider roster. *

Provider Name Degree / Role Individual NPI State License(s) Board / Training DEA / Prescribing Rendering Location(s) Enroll? Action

Provider Degree / Role Options *

Board / Training Options

Section 9 - Locations & Service Delivery Information

Add each practice location below. Each location uses the same address format as the Primary Practice Address. Check “Same as Primary Practice Address” to copy the primary address automatically.*

Expected Place of Service Codes

Section 12 - Existing Provider Enrollment & Payer Details

Payer Types *

Participation Preference

Section 10 - Coding Inventory Worksheet

A. Common Medical CPT / HCPCS Codes

CodeDescriptionFrequency (H/M/L)NotesAction

B. Common CDT Dental Codes

CodeDescriptionFrequency (H/M/L)NotesAction

8. Software & Connectivity

Section 15 - Upload Supporting Documents

Provider and entity documents should be uploaded only through the secure upload fields below.

Sections 5, 13 & 14 - Key Project Information, Compliance & Additional Notes

Privacy, Security & Technology Requirements

Please review the following requirements carefully before submitting this credentialing 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 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.
  • 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 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 an 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 failure to disclose the exact type of physical location can result in delays, denials, enrollment rejection, site visit failure, 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 requirements above.

Section 21 - Client Acknowledgements, Signatures & Certification

By signing below, the authorized signer certifies that the information provided is true, complete, and accurate to the best of their knowledge, and authorizes TriumpHealth to use this information to evaluate credentialing, enrollment, contracting, billing setup, compliance, payer participation, and related service requirements.

Choose Signature Method

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