Credentialing Form

1
Email
example@example.com
2
Today's Date
Date
Month
Day
Year
3
What's your full legal name?* This field is required.
4
What is your personal email* This field is required.
example@example.com
5
If you would like regular updates on the status of your credentialing application, please add the email address where updates are to be sent
Notification Email
6
What is your home address?
7
What is your personal cell phone number?* This field is required.
Please enter a valid phone number.
8
What's your Date of Birth?
Date
Month
Day
Year
9
What's your Social Security Number?* This field is required.
10
What university did you attend for your highest degree?* This field is required.
11
What type of degree were you awarded?
12
When did you graduate with your highest degree?* This field is required.
Date
Month
Day
Year
13
What type of professional license do you hold?
14
Effective Date of Professional License* This field is required.
Date
Month
Day
Year
15
Expiration Date of Professional License* This field is required.
Date
Month
Day
Year
16
Professional License Number* This field is required.
17
Adverse Action Against License* This field is required.
Yes
No
18
Individual NPI (Type I)* This field is required.
19
CAQH Number
Please be sure to add the following information to your CAQH under the Credentialing Contacts section AND re-attest before we begin credentialing. Credentialing Name- Samantha Mahon Address: 800 W. Williams Street, Ste 280 Apex, NC 27502Phone #- 919-412-5685 Fax #- 919-355-5694
20
Ages Served
Kids
Teens
Adults
Couples
Kids+Teens
Kids+Teens+Adults
Teens+Adults
Teens+Adults+Couples
Adults+Couples
Kids+Teens+Adults+Couples
21
Are you fluent in any other languages)?
Yes
No
22
Fluent Language
If yes, please add the language in the box, if no- leave blank
23
Legal Name of Practice* This field is required.
24
Legal StructurePLLC. LLC, PA
25
Address of Service Location (Practice Address)
26
Billing Address of Practice
27
Practice Phone Number (for Appointments & follow up)* This field is required.
Please enter a valid phone number.
28
Practice Fax Number
Please enter a valid phone number.
29
Practice Email* This field is required.
example@example.com
30
Practice Website
31
Group NPI* This field is required.
32
Practice Tax Id* This field is required.
33
Telehealth Options
Virtual Only
Hybrid (in-person & telehealth)
I don't offer telehealth
Other
34
Do you authorize Peak Practice Solutions, LLC to sign application forms on your behalf?* This field is required.
Yes, I agree
No, I want to sign my own forms (this will delay processing)
35
What Insurance Companies would you like to get credentialed with?Add as many insurance companies as you would like below
36
Do you have any other information that we may need to do the credentialing for you? You can add questions here as well!
37
Professional Resume/CV Upload
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
38
Liability Insurance Declaration Page
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
39
Copy of Professional License
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
40
Email
example@example.com
Should be Empty: