Initial Credentialing Application Checklist - Cal Care IPA

Initial Credentialing Application Checklist If you are a CAQH (Council for Affordable Quality Healthcare) provider please provide your CAQH number CAQH#: _____ California Participating Physician Application (CPPA) P lease ensure the entire Application is completed in its entirety and the attestation Questions page and Information Release/Acknowledgements page has a current date Addendum A, completed, signed and dated Addendum B, completed, signed and dated. Attach copies of malpractice claims history and explanation in the providers own words, if applicable Addendum C Provider Health History, completed, signed and dated. Medi-Cal # required Addendum D PPMC Provider Rights/Responsibilities form Addendum E, Provider Care Experience, completed, signed and dated Addendum F, HIV attestation , Only applicable for Internal Medicine and Infectious Disease Provider Addendum G, PPMC Provider Work History Form or Page 6 of the Application (Explanation for any gap of 6 months or greater)(Document dates at mm/yyyy).

Initial Credentialing Application Checklist . If you are a CAQH (Council for Affordable Quality Healthcare) provider please provide your CAQH number . CAQH#: _____ California Participating Physician Application (CPPA) – P lease ensure the entire application is completed in its entirety and the Attestation Questions page and Information Release/Acknowledgements page has a current date

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