Provider Credentialing Application - Align Networks

(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 (if applicable):_____ Facility/ Provider Tax Identification #:_____ Medicare Provider # (if applicable): _____ Group/Facility NPI #: _____ What type of billing form is utilized by your facility/facilities?

(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):

Loading..

Tags:

  Applications, Provider, Pages, Credentialing, Provider credentialing application

Information

Related search queries