DaVita Credentialing Request Form 2014 free printable template
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Credentialing Services 5200 Virginia Way Brentwood, TN 37027 Tel: 800-467-4736 Fax: 615-341-5878 www.davita.com Credentialing Request Form Please select the option that best fits your request: REQUIRED
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How to fill out DaVita Credentialing Request Form
How to fill out DaVita Credentialing Request Form
01
Obtain the DaVita Credentialing Request Form from the official DaVita website or your local DaVita office.
02
Fill in your personal information, including your full name, contact information, and practice address.
03
Provide details about your medical education and training, including the names of institutions and years attended.
04
List your current and past medical licenses, including license numbers and expiration dates.
05
Fill in any certifications relevant to your specialty, along with expiration dates if applicable.
06
Provide the names and contact information for your malpractice insurance provider.
07
List your work history, including the names of all employers and duration of employment.
08
Answer any questions regarding your clinical privileges and current practice.
09
Review the form for accuracy and completeness before submission.
10
Submit the completed form as directed, either by email or mail.
Who needs DaVita Credentialing Request Form?
01
Healthcare providers seeking to join DaVita's network.
02
Physicians, nurse practitioners, and physician assistants who provide renal care services.
03
Medical professionals applying for privileges at DaVita facilities.
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What is DaVita Credentialing Request Form?
The DaVita Credentialing Request Form is a document used to collect necessary information about healthcare providers seeking to be credentialed by DaVita, a healthcare company specializing in kidney care.
Who is required to file DaVita Credentialing Request Form?
Healthcare providers, including physicians and allied health professionals, who wish to join DaVita's network and provide services must file the DaVita Credentialing Request Form.
How to fill out DaVita Credentialing Request Form?
To fill out the DaVita Credentialing Request Form, individuals should provide their personal and professional information, including medical licenses, work history, education, and any relevant certifications. It is important to ensure all information is accurate and complete.
What is the purpose of DaVita Credentialing Request Form?
The purpose of the DaVita Credentialing Request Form is to ensure that healthcare providers meet the standards and requirements set by DaVita for providing quality care to patients. It helps verify the qualifications and credentials of the applicants.
What information must be reported on DaVita Credentialing Request Form?
The information that must be reported on the DaVita Credentialing Request Form includes personal identification details, professional qualifications, work history, education background, training, certifications, and any disciplinary actions or malpractice claims.
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