Date of Request:
Agency Name requesting to add clinician:
Agency Practice Address:
Clinician’s Name
(as it appears on professional license):
Clinician’s Email:
Is Clinician currently credentialed with Alliance? Yes No
Applicable License Type(s) (list all):
License Number(s) (list all):
NPI Number:
Is Clinician registered with CAQH?
Yes (Provide Number):
No (Provide Date of Birth to receive registration information):
Hire Date (for HOSPITALS ONLY):
Name of Person Submitting Request:
Contact Email (where application will be sent):
Please complete request and email to: