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Mid-Valley Behavioral Care Network PROVIDER RE-CREDENTIALING APPLICATION Please type or print all application information. 1. IDENTIFYING INFORMATION 1.1 Name of Applicant Agency 1.2 Director's Name

How to fill out provider re-credentialing application

How to fill out a provider re-credentialing application:

1. Gather necessary documentation: Start by gathering all the required documents such as your current license, certificates, current malpractice insurance, and any other supporting documentation that may be requested.
2. Review the application instructions: Carefully read through the instructions provided with the application form. It will outline the specific requirements and details on how to complete each section accurately.
3. Complete personal information: Begin by filling out your personal information section, including your full name, contact details, address, and any other relevant information.
4. Provide professional history: Detail your professional history, including your educational background, training programs attended, work experience, and any additional relevant information.
5. Include current affiliations: List all the current affiliations you have with healthcare facilities or organizations, including hospitals, clinics, or medical practices.
6. Submit current licenses and certifications: Attach copies of your current licenses and certifications, ensuring that they are valid and up to date.
7. Complete disclosure section: Provide any necessary disclosures about past legal actions, malpractice claims, or disciplinary actions, if applicable.
8. Include current malpractice insurance: Provide proof of your current malpractice insurance coverage, including the policy details and any relevant documentation.
9. Submit supporting documentation: Include any additional supporting documentation required, such as your curriculum vitae, letters of recommendation, or patient satisfaction surveys.
10. Sign and date the application: Once you have completed all the necessary sections of the application, sign and date it before submitting it to the appropriate authority.

Who needs a provider re-credentialing application?

1. Medical professionals seeking to maintain their credentials: Healthcare providers such as doctors, nurses, dentists, and other medical practitioners need to undergo re-credentialing to maintain their licensure and accreditation.
2. Healthcare facilities and organizations: Hospitals, clinics, medical practices, and other healthcare organizations often require their providers to complete a re-credentialing application to ensure they meet the necessary qualifications and standards.
3. Insurance companies and payers: Insurance companies and third-party payers may require providers to go through re-credentialing to ensure that they continue to meet the necessary standards and qualifications for reimbursement purposes.

For pdfFiller’s FAQs

What is provider re-credentialing application?

Provider re-credentialing application is the process by which healthcare providers update their information and qualifications to maintain their participation with insurance companies and healthcare organizations.

Who is required to file provider re-credentialing application?

All healthcare providers who participate in insurance networks or work with healthcare organizations are required to file provider re-credentialing applications.

How to fill out provider re-credentialing application?

Providers must complete the application form with accurate and up-to-date information about their credentials, education, training, licensure, and work history.

What is the purpose of provider re-credentialing application?

The purpose of provider re-credentialing application is to ensure the continued competence and qualifications of healthcare providers, as well as maintaining compliance with insurance and regulatory requirements.

What information must be reported on provider re-credentialing application?

Providers must report their education, training, licensure, work history, malpractice history, professional references, and any disciplinary actions or legal issues.

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