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Facility/Ancillary Application

The following application is to initiate credentialing or recredentialing for facility and ancillary providers only. Individual practitioners should complete the credentialing application per their licensure. The below documents may be required, contingent on provider type:

– W9
– Active, unencumbered state license
– Certificate of professional liability insurance
– Accreditation certificate (e.g. TJC, AAAHC, AAAASF, AOA, CARF, CHAP, CCAC) and/or
– Most recent CMS or state agency survey, of less than 3 years

Initial Applicants only: A representative will contact you within 30 days of submission with eligibility determination and contracting documents, as applicable.

Questions about the application may be directed to our Credentialing Department at (800) 801-9772, option 4, option 2 or FacilityCredentialing@ProviDRsCare.Net.