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 Not for profit Partnership Sponsorship Hospital Sole Proprietorship Privately Held Other Organization Facility/ Provider Information - General Information: Facility/ Provider Legal Name: ________________________________________ ________________________ Facility/ Provider DBA ()

(10/24/14) Page 8 of 13 Professional Work History - Please provide practice history, including month and year, for the past FIVE (5) years. An explanation is required for any gap of six (6) months or longer that appear in your Professional Work History.

  Applications, Provider, Credentialing, Provider credentialing application