Fillable Provider Credentialing Form

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Provider Credentialing Form

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The Provider Credentialing Form form is 4 pages long and contains:

  • 1 signature
  • 95 check-boxes
  • 216 other fields

Country of origin: OTHERS
File type: PDF

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Thank you for your interest in becoming an EmblemHealth participating provider. EmblemHealth and the Council for Aordable Quality Healthcare (CAQH)
have joined forces to provide an online credentialing application database. To update your application or learn more about CAQH Proview, visit www.caqh.org.
Add EmblemHealth to your list of “Authorized Health Plans” or choose the “Global Access” option and update your application to reflect current information.
Note: If you are a behavioral health, musculoskeletal services (physical therapy, occupational therapy, or chiropractic), dental, or vision services provider, please
refer to EmblemHealth’s Join Our Networks page (https://www.emblemhealth.com/providers/resources/join-our-network) before using this form. You may be
required to apply through one of our partners for participation with EmblemHealth.
This form and a W-9 must be completed to begin the credentialing process. Please complete and submit by email:
• For applicants in New York City’s five boroughs, Nassau and Suolk counties, New Jersey, and Connecticut, please send your completed application and
agreement(s) to: CredentialingNYC@emblemhealth.com.
• For applicants in all other counties in New York State and other states, please send your completed application and agreement(s) to:
CredentialingSYR@emblemhealth.com.
Please note: The email addresses above are for the submission of new applications only. Our Credentialing team will reach out to you if additional information is
needed. We recommend waiting at least 45 days before checking on the status of your application. To check status, call our Provider Services Line at 8778423625.
To be listed in the directory for a specific location, the provider must actively be seeing patients at the location on a regular and consistent basis but, in no event,
less than once per week. A “regular and consistent basis” does not include covering physicians who are in the oce occasionally.
To begin the application process, please complete the following: (Please print legibly)
Provider Last Name: Provider First Name: Gender:
SSN#: NPI: CAQH ID #: State/State License #:
Are you enrolled in Medicare?
Yes No
Federal DEA #:
Credentialing Contact: Credentialing Email: Credentialing Phone:
Joining a group practice?
Yes No
Group Name: Tax ID:
Do you have privileges at an Ambulatory Surgery Center?
Yes No. If yes, please indicate the name and address of the facility:
Adding Tax ID: Terminating Tax ID:
State:
NY NJ CT FL Other
Line of Business:
Commercial/CHP Medicare Medicaid
Practitioner Type: (select one) PCP* Specialist Allied Health Professional*
APRN/NP must attach your Nursing Certification and Collaborative Agreement
PCP only:
Number of working hours per week: _____________________________________
Are you accepting new patients?
Yes No
**Midlevel providers only: Provide the name of your supervisor/collaborating physician: __________________________________________________________________________________________
Do you practice exclusively in an inpatient setting, i.e., patients cannot call and make an appointment to see you?
Yes No
If yes, please list hospital:
Does your oce provide online services, i.e., prescription refills, appointments, clinical questions, etc.?
Yes No
SPECIALTY to appear in the Directory:
Board certified?
Yes No N/A
If yes, please list board:
RECRUITED SERVICE ADRESSES
To ensure appropriate listing in our provider directories, please confirm the following detail on each service location from your CAQH application:
ADDRESSES RECRUITED:
All on CAQH under TIN above (complete section 1 only) Limited to the following below: (complete sections 1 and 2)
If more than 6 locations: (complete section 1 and attach list of all service locations on letterhead)
Provider Credentialing Form
EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, Health Insurance Plan of Greater New York (HIP) and EmblemHealth Insurance Company of New Jersey are EmblemHealth
companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.
EMB_PR_FRM_47898_CredApp 12/20
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SUBMIT
SECTION 1: PRIMARY LOCATION
1. Address:
Service Address:
Yes No
Can patients make appointments with you at this address?
Yes No
Should location print in the Directory?
Yes No
Appointment Phone #:
Are there any age restrictions to your practice?
Yes No
Ages:
0 – 20 yrs 21 yrs and over OR Indicate minimum age _________________ indicate maximum age _________________
(In-Oce) (Inpatient hospital) (Outpatient hospital) (Ambulatory surgical center)
Do you see patients on a regular and consistent basis, at least one day a week, in the above location?
Yes No
Payment address same as: Practice Mailing Other Street Address:
City: State: ZIP:
Mailing address same as:
Practice Mailing Other Street Address:
City: State: ZIP:
Mailing Oce Phone #: Mailing Oce Fax #:
SECTION 2: ADDITIONAL OFFICES
2. Address:
Service Address:
Yes No
Can patients make appointments with you at this address?
Yes No
Should location print in the Directory?
Yes No
Appointment Phone #:
Are there any age restrictions to your practice?
Yes No
If dierent TIN, W-9 attached?
Yes No
TIN:
Ages:
0 – 20 yrs 21 yrs and over OR Indicate minimum age _________________ indicate maximum age _________________
(In-Oce) (Inpatient hospital) (Outpatient hospital) (Ambulatory surgical center)
Do you see patients on a regular and consistent basis, at least one day a week, in the above location?
Yes No
Payment address same as: Practice Mailing Other Street Address:
City: State: ZIP:
Mailing address same as:
Practice Mailing Other Street Address:
City: State: ZIP:
Mailing Oce Phone #: Mailing Oce Fax #:
3. Address:
Service Address:
Yes No
Can patients make appointments with you at this address?
Yes No
Should location print in the Directory?
Yes No
Appointment Phone #:
Are there any age restrictions to your practice?
Yes No
If dierent TIN, W-9 attached?
Yes No
TIN:
Ages:
0 – 20 yrs 21 yrs and over OR Indicate minimum age _________________ indicate maximum age _________________
(In-Oce) (Inpatient hospital) (Outpatient hospital) (Ambulatory surgical center)
Do you see patients on a regular and consistent basis, at least one day a week, in the above location?
Yes No
Payment address same as: Practice Mailing Other Street Address:
City: State: ZIP:
Mailing address same as:
Practice Mailing Other Street Address:
City: State: ZIP:
Mailing Oce Phone #: Mailing Oce Fax #:
Provider Credentialing Form
(Continued)
4. Address:
Service Address:
Yes No
Can patients make appointments with you at this address?
Yes No
Should location print in the Directory?
Yes No
Appointment Phone #:
Are there any age restrictions to your practice?
Yes No
If dierent TIN, W-9 attached?
Yes No
TIN:
Ages:
0 – 20 yrs 21 yrs and over OR Indicate minimum age _________________ indicate maximum age _________________
(In-Oce) (Inpatient hospital) (Outpatient hospital) (Ambulatory surgical center)
Do you see patients on a regular and consistent basis, at least one day a week, in the above location?
Yes No
Payment address same as: Practice Mailing Other Street Address:
City: State: ZIP:
Mailing address same as:
Practice Mailing Other Street Address:
City: State: ZIP:
Mailing Oce Phone #: Mailing Oce Fax #:
5. Address:
Service Address:
Yes No
Can patients make appointments with you at this address?
Yes No
Should location print in the Directory? Yes No
Appointment Phone #:
Are there any age restrictions to your practice?
Yes No
If dierent TIN, W-9 attached?
Yes No
TIN:
Ages:
0 – 20 yrs 21 yrs and over OR Indicate minimum age _________________ indicate maximum age _________________
(In-Oce) (Inpatient hospital) (Outpatient hospital) (Ambulatory surgical center)
Do you see patients on a regular and consistent basis, at least one day a week, in the above location?
Yes No
Payment address same as: Practice Mailing Other Street Address:
City: State: ZIP:
Mailing address same as:
Practice Mailing Other Street Address:
City: State: ZIP:
Mailing Oce Phone #: Mailing Oce Fax #:
6. Address:
Service Address:
Yes No
Can patients make appointments with you at this address? Yes No
Should location print in the Directory? Yes No
Appointment Phone #:
Are there any age restrictions to your practice?
Yes No
If dierent TIN, W-9 attached?
Yes No
TIN:
Ages:
0 – 20 yrs 21 yrs and over OR Indicate minimum age _________________ indicate maximum age _________________
(In-Oce) (Inpatient hospital) (Outpatient hospital) (Ambulatory surgical center)
Do you see patients on a regular and consistent basis, at least one day a week, in the above location?
Yes No
Provider Credentialing Form
(Continued)
Payment address same as: Practice Mailing Other Street Address:
City: State: ZIP:
Mailing address same as:
Practice Mailing Other Street Address:
City: State: ZIP:
Mailing Oce Phone #: Mailing Oce Fax #:
PLEASE ATTACH THESE ITEMS TO APPLICATION:
W-9 (all W-9s referenced in Recruited Service Addresses section must be signed and dated)
Participating hospital privileges or coverage arrangements with participating provider:
Collaborative agreement (If applicable)
• Nurse Practitioner Services
• Physician Assistant Services
• Midwifery Services
Participating hospital privileges or coverage arrangements with participating provider
ADA Attestation completed for each HMO service location submitted
This form and a W-9 must be completed to begin the credentialing process.
EmblemHealth makes its Administrative Guidelines, including but not limited to, the EmblemHealth Provider Manual (which includes the credentialing
criteria and your rights during the process), Medical Policies, Clinical Practice Guidelines, Appointment Availability & After Hours Access Standards,
Referral, Preauthorization requirements, policy updates, and other participation requirements and useful tools, available on emblemhealth.com/providers.
I understand that in applying for participation with EmblemHealth and its companies, I am agreeing to review and comply with these terms. I am responsible
for checking emblemhealth.com/providers for updates and for providing a valid email address to EmblemHealth so updates may be sent to me.
By checking this item, I am acknowledging receipt of the EmblemHealth Provider Manual, which is available online. If I cannot access the manual
online, I acknowledge that I have called EmblemHealth’s Provider Customer Service at 866-447-9717 to request a copy of the manual.
I hereby attest, the provider(s) covered by this application have completed the current years’ EmblemHealth Special Needs Plan (SNP) Model of Care
(MOC) training link located at https://www.emblemHealth.com/providers/resources/news/dsnp-provider-training, which is required by the Centers for
Medicare & Medicaid Services (CMS). I declare the above statement is true and accurate to the best of my knowledge. Additionally, this will confirm I hold
the authority to make this attestation on behalf of all providers covered by this application.
Required attestation information completed by (Signature):
First Name (Please print): Last Name (Please print): Date Signed:
Relationship to above-named provider (e.g., self, oce manager, nurse, other):
Applicants have the right to review the information submitted in support of their application and to correct erroneous information. EmblemHealth will
notify the applicant of any information obtained during the credentialing process that varies substantially from the information submitted.
Provider Credentialing Form
(Continued)
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Provider Credentialing Form

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Completed 31 July 2021

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