First Name:

Last Name:

Organization:

Your Title:

Email:

Phone:

Fax:

Address:

City:

State:

Zip Code:

What is your total number of providers?

Please enter the types of providers you credential:
(ie. MD, DO, DDS, PHD, MSW, PA)

How many NEW applications do you process annually?

Which items do you require for New Applicants?
State medical license
Federal DEA or CDS certificate
Malpractice coverage
Malpractice claims history
License sanctions
HFCA Medicare/Medicaid sanctions
Medical education
Post graduate training
Board certification
Professional References
Primary hospital affiliation
All hospital affiliations and clinical privilege requests

Any other items not listed:

What accreditation are you seeking?
NCQA
JCAHO
URAC
AAAHC

What is the date of your next survey?

Do you currently query the National Practitioner Data Bank?
Yes
No

Are you newly starting to credential your providers, or are you interested in outsourcing an existing program?
Start Now
Outsourcing

Comments or Questions