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The above button links to a printable version. The downloadable file contains the page application and supplemental forms and reference codes. The supplemental forms allow you to provide additional information where appropriate. The reference codes are used to answer questions specific to your license type. If you do not have Adobe Acrobat Reader click here for a free download.

Uniform credentialinfg form

Uniform Recredentialing Form in Adobe Acrobat. Sign and date the application. A carrier or its credentialing intermediary shall: 1 Accept the uniform credentialing form as the sole application for a health care credentialinfb to become credentialed or recredentialed Uniform credentialinfg form a provider panel of the carrier; and 2 Make the uniform credentialing form available to any health care provider Uniform credentialinfg form is to be credentialed or recredentialed by the carrier or credentialing intermediary. Initial Appointment and Reappointment Please complete each section thoroughly and truthfully. Attach additional sheets The private sex survivor necessary. Modification to the wording and format of the form will invalidate the application. Schedule A.

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Click a document below to download Physician Initial Application Part 1.

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  • Become a member of the Minnesota Credentialing Collaborative and data required for the Minnesota Uniform Credentialing application follows you wherever you go.
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  • In accordance with legislation enacted by the West Virginia Legislature in , the Uniform Credentialing Advisory Committee was appointed by the Secretary of the Department of Health and Human Resources and the West Virginia Insurance Commissioner to assist in developing a uniform credentialing process and implementing the use of uniform credentialing forms.
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In accordance with legislation enacted by the West Virginia Legislature in , the Uniform Credentialing Advisory Committee was appointed by the Secretary of the Department of Health and Human Resources and the West Virginia Insurance Commissioner to assist in developing a uniform credentialing process and implementing the use of uniform credentialing forms.

During and , the Uniform Credentialing Advisory Committee developed the standardized forms with the goal of reducing the need for healthcare practitioners to complete multiple forms containing the same or similar information during the application and re-application process required by various entities.

The uniform credentialing and recredentialing forms were originally implemented on July 1, and were amended effective October 28, The original legislative rule is designated 64 CSR The legislative rule will no longer contain the forms and list of practitioners, but should be consulted for additional requirements relating to the use of the forms.

The Healthcare Entity may require additional information along with this standardized form. The Standardized Credentialing Form must be utilized by Hospitals, Health Plans, and other Healthcare Entities at the time the practitioner is originally credentialed. The Re-credentialing Form must be utilized by these Hospitals, Health Plans, and other Healthcare Entities at the time you apply for reappointment. Please complete each section thoroughly and truthfully. Modification to the wording and format of the form will invalidate the application.

Attach additional sheets where necessary. Indicate clearly the practitioner name and applicable section on each attachment. Type or print legibly in black ink. Sign and date the application. Some entities may require signature to be in blue ink. After completion of the application, you may photocopy and then submit with a signed attestation to each entity to which you wish to apply.

A listing of required documentation needed to complete the application process is contained on the first page of the application form. You are responsible for providing current information at all times and to update substantial changes throughout the credentialing period. Please remember that you must sign and date a new attestation page each time your form is submitted.

Do not submit forms to the Offices of the Insurance Commissioner. Get Adobe Acrobat Reader. Uniform Credentialing Form in Microsoft Word. Uniform Credentialing Form in Adobe Acrobat.

Uniform Recredentialing form in Microsoft Word. Uniform Recredentialing Form in Adobe Acrobat. History of Uniform Credentialing Forms. Uniform Credentialing Application Forms. General Instructions. Initial Appointment and Reappointment.

Initial Appointment and Reappointment Please complete each section thoroughly and truthfully.

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Uniform credentialinfg form

Uniform credentialinfg form

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Username and Password Help. New Providers Start Here Hospitals, payers can ease provider angst For years, applying for credentials has been at the top of health care providers' list of administrative hassles. Member Log In. Clinic Administrator You manage provider records for your practice. Individual Provider You are an individual provider here to work in your account.

Sign up here to receive advance notification when the system will be unavailable. Send us your name and email address. News and Updates. Refund Policy Reminder. Clinic Administrator. Individual Provider. The Health Care Credentials and Data Collection Act requires uniform forms to be utilized in order to collect the credentials data commonly requested by health care entities and health care plans for purposes of credentialing and recredentialing.

Please contact the health care plan, health care entity or hospital that is reviewing your credentials for instructions on where to send this form and any other information it may require in order to complete the credentialing process. What constitutes a change of ownership?

Refer to Section See related Links. What is required for a relocation of the health care provider? See link. In addition, if the Facility is Medicare certified the provider shall complete the Medicare Provider enrollment form A or B and submit to their Medicare fiscal intermediary. Every hospital required to be licensed by IDPH that provides general medical and surgical hospital services, shall provide either transfer services; hospital emergency services and forensic services for adults, with transfer of pediatrics; or hospital emergency services and forensic services for all ages to all sexual assault survivors in relation to injuries or trauma resulting from a sexual assault.

Each facility operating under an Area Wide Plan is required to submit its individual plan along with the Area Wide Plan. Hospitals operating under an Area Wide Plan should coordinate with other facilities operating under the same Area Wide Plan on the timing of submission so that plans can be reviewed comprehensively.

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Click a document below to download Physician Initial Application Part 1. Click a document below to download. Physician Initial Application Part 1. Physician Initial Application Part 2. Physician Recredentialing Reappointment. Initial Application with NPI field. Additional application information - for Managed Care Organizations. AHP Recredentialing Reappointment. Recredentialing Application with NPI field.

Schedule A. Schedule B. Schedule C.

Uniform credentialinfg form

Uniform credentialinfg form

Uniform credentialinfg form