Provider Initial Intake Form

To ensure a smooth and efficient credentialing process, please complete and return all
requested information promptly. Missing or incomplete documentation may result in delays.
Your cooperation is greatly appreciated.

Copies of the following documents will be required to complete your submission, so please be sure to have them available:

Attestation
Board Certification(s)
Collaborative Agreement (if applicable)
Curriculum Vitae (CV) – Please explain any gaps of 6 months or more
DEA Certificate
Delegated (Collaborative) Service Agreement – Midlevel providers only
Diploma or Transcript
Driver’s License
ECFMG Certificate (if applicable)
Education and Training Certificate(s)
Malpractice Insurance
Medical License (all past and present)
Rx Authority (if applicable)
Any Additional Licenses

Provider Intake Form

Group/Facility You are With(Required)

Name(Required)

First Name Middle Name Last Name

Known by any other names?

Last Name

Middle Name

Last Name

Gender(Required)

Effective Date with Practice(Required)

Specialty(Required)

NPI(Required)

Date of Birth(Required)

SSN(Required)

Personal Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Personal Phone Number

Personal Email Address

Location Address(es) Where You will be Providing Services(Required)

Medicaid Login Information

Email Username Password

PECOS Staff End User Instructions

1) Login to your I & A Account: Identity & Access Management System (CMS)
Note: Your login credentials are the same as your NPPES login.

2) Click the tab called “My Staff”.
3) Click the “Add Staff” tab.

4) Add the staff member information:
Rachel Stephens
Email: [email protected]

5) Under the Role section:
Select “Staff End User” from the dropdown and check both “PECOS” and “NPPES”.

A notification will be sent once the request has been submitted.

CAQH ID(Required)

CAQH Login(Required)

CAQH Password(Required)

If you are unsure or do not have your CAQH information:

• Call CAQH at 888-599-1771 for assistance
• Or visit https://proview.caqh.org and click “Forgot Password” to follow the reset instructions

Required Uploads

Please upload all required documents before submitting this form. Accepted file formats include PDF, JPG, and PNG.

Board Certification(s)(Required)

Max. file size: 800 MB.

Collaborative Agreement (if applicable)

Max. file size: 800 MB.

Curriculum Vitae (CV): If any gaps of 6 months+, please provide an explanation.(Required)

Max. file size: 800 MB.

DEA Certificate

Max. file size: 800 MB.

Delegated (Collaborative) Service Agreement- Midlevel's ONLY

Max. file size: 800 MB.

Diploma or Transcript(Required)

Max. file size: 800 MB.

Driver's License / Passport(Required)

Max. file size: 800 MB.

ECFMG (If Applicable)

Max. file size: 800 MB.

Education and Training Certificate(s)

Max. file size: 800 MB.

Malpractice Insurance

Max. file size: 800 MB.

Medical License (All Past and Present)(Required)

Max. file size: 800 MB.

Rx Authority (if applicable)

Max. file size: 800 MB.

Any Additional Licenses

Max. file size: 800 MB.

Electronic Signature Consent

Need a copy of the Electronic Signature Consent? Download it here

Please review, complete, and sign this form prior to submission.

Max. file size: 800 MB.