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 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.

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  Applications, Provider, Credentialing, Provider credentialing application

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