Credentialing Group/Facility Intake Form

Group Information – Required Documents

IRS Document (CP575 Form) – Provides proof of ownership, Tax ID number, and legal business name.
Form W-9 – Must list the group’s pay-to/remittance address and be signed and dated by the Authorized Official.
Bank Letter or Voided Check – Used for EFT enrollment and verification of banking information.
Certification Copies – JCAHO, AAAASF, AAAHC, or other applicable accreditations.
CLIA Certificate or Waiver – If applicable to services provided.

Credentialing Group/Facility Intake Form

Corporate Information(Required)

Corporation Name

Corporation DBA (if applicable)

Corporation Address(Required)

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

Company Mailing Address(Required)

Same as previous

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

Company Billing/Remittance Address(Required)

Same as previous

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

Company Telephone Number(Required)

Company Fax Number(Required)

Hours of Operation(Required)

Age Limitations(Required)

Type of Practice(Required)

Practice Type (eg: Hospital, Urgent Care, Medical Group, Surgery Center, etc.)

NPI II (Group NPI)(Required)

Tax ID Number(Required)

List all Additional Location Addresses

Authorized Official / Ownership Information(Required)

First Name Last Name

Please provide the names of all corporate owners along with their respective ownership percentages.(Required)

Name

Ownership Percentage

Please list all Driver's License, Social Security numbers, and Dates of Birth for all owners.(Required)

Full Name

SSN

DL Number

DOB

Point of Contact Information(Required)

POC First Name POC Last Name

POC Phone Number(Required)

POC Email Address(Required)

Payor Enrollment List

Please List all Payors that you would like to be enrolled with, as well as the line of business.

Payor Maintenance List

Please List all Payors that you would like Emerge and See to take over Maintenance with.

Current Medicaid and Medicare numbers (if applicable).

Medicaid Medicare

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.

Medicaid Username and Password (applicable by State)

Username Password

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

Group Availity Login Information

Username Password

Group UHC/Optum Login Information

Username Password

Required Uploads

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

IRS Document (CP575 Form)(Required)

Shows carriers proof of ownership, tax ID number and legal business name.

Max. file size: 800 MB.

Business Associate Agreement(Required)

Download the Business Associate Agreement (BAA)

Max. file size: 800 MB.

Form W9(Required)

Need a copy of the W-9? Download it here

The W-9 must list the group’s pay-to/remittance address and be signed and dated by the Authorized Official.

Max. file size: 800 MB.

Bank Letter / Voided Check(Required)

For submission to multiple carriers for EFT enrollment and proof of banking information.

Max. file size: 800 MB.

Certification Copies (if applicable)

JCHAO, AAAASF, AAAHC, etc.

Max. file size: 800 MB.

Copies of CLIA Certificates or Waivers (if applicable)

Max. file size: 800 MB.

Credit Card Authorization Form

Need a copy of the Credit Card Authorization form? Download it here

Please complete all fields and ensure the form is signed by an Authorized Representative.

Max. file size: 800 MB.