Credentialing Request Form

Use this form if you need to:

Request verification of new-hire enrollment status with contracted payors that require individual credentialing
Request verification of out-of-network status for credentialed/enrolled providers or centers
Review NPI discrepancies
Request a review of provider directory discrepancies, including missing or incorrect location
Review claim denials for credentialed or enrolled providers or centers

Submitter Name (Required):
Submitter Email (Required):
Type of Request (Required):
Was Care Rendered by a PT, OT, or SLP?:
Description (Required):
Patient Name (Required):
Patient Date of Birth:
Patient Member ID #:
Date of Service – Initial Date:
Date of Service – End Date:
Client/Payor/Insurance Plan (Required):
Network:
Financial Class:
Reference Number:
Insurance Representative Name:
Insurance Representative Phone #:
Rejection/Denial Reason:
Total Billed Charges/Financial Impact:
Taxonomy Code (if Managed/Medicaid):
Clinician Name and Credentials:
Clinic Name:
Clinic Address:
Clinic City:
Clinic State (Required):
Clinic Zip Code: