CredentialsOnLine Contact Form

CredentialsOnLine contact form.
Please fill out the information below.

1. General Information

First Name:

Last Name:

Title:

Email:

Org Name:

Phone:

Fax:

Address:

City:

State

Zip:

2. What is your total number of providers?

3. Please enter the types of providers you credential: (i.e. MD, DO, DDS, PhD, MSW, PA

4. How many NEW applications do you process each month?

5. Which items do you require for New Applicants?

	State medical license
	Federal DEA or CDS certificate
	Malpractice coverage
	Malpractice claims history
	License sanctions
	HFCA Medicare/Medicaid sanctions
	Medical education
	Post graduate training
	Board certification
	Professional references
	Primary hospital affiliation
	All hospital affiliations and clinical privilege requests
	Continuing medical education (CME) courses
	Academic/Faculty appointments

Any other items not listed:

6. Are you seeking NCQA accreditation?

7. Are you seeking JCAHO accreditation?

8. What is the date of your next survey?

9. Will you use an electronic (Internet) application?

10. Do you currently query the National Practitioner Data Bank?

Please enter any questions or comments below.