Provider Credentialing Application - Align Networks

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(10/24/14) Page 1 of 13 Provider Credentialing Application Key Contact Information (Please supply high level contacts for each of the following areas in your organization): Contracting: Name: ____________________ Phone: ______________________Email:____________ ________________ Clinical: Name: ____________________ Phone: ______________________Email:____________ ________________ Billing: Name: ____________________ Phone: ______________________Email:____________ ________________ Corporate: Name: ____________________ Phone: ______________________Email:____________ ________________ Credentialing : Name: ____________________ Phone: ______________________Email:____________ ________________ Scheduling: Name: ____________________ Phone: ______________________Email:____________ ________________ Corporate/Main Office Information: Address: ________________________________________ ________________________________________ Phone Number: _______________ Fax Number: _______________ E-Mail Address: ___________________ Ownership and Management: Check all that apply: Corporation For Profit N

(10/24/14) Page 1 of 13 Provider Credentialing Application Key Contact Information (Please supply high level contacts for each of the following areas in your organization):

  Applications, Provider, Credentialing, Provider credentialing application