Individual Provider Onboarding Form

Individual Enrollment Onboarding Form

Please complete all sections accurately.

Personal Information

Full Legal Name

Gender

NPI

SSN

Date of Birth

Ethnicity

Please specify ethnicity

Birth City

Birth Country

Contact & Address

Primary Home Address

Address Line 2

City

State

Zip Code

Is your Billing/Correspondence Address the same as your Home Address?

Phone

Primary Email

Other Email(s)

Practice Details

What is your start date with your company / group?

Are you enrolled in Medicare as a participating provider?

In which states?

Are you enrolled in Medicaid as a participating provider?

In which states?

Portal Login Information (Medicaid, EyeMed, etc.)

Telehealth Services (Audio/Video)

Video Platforms Used (Google, Simple Practice, etc.)

Disclosures

CAQH Information

CAQH ID Number

CAQH Username

CAQH Password

I need assistance setting up my CAQH profile

Payers You'd Like to Be Credentialed With

Enter one company in the box below, check the boxes for Medicare, Medicaid, and/or Commercial, then click Add Insurance. Repeat this for each individual payer you wish to credential with.

Insurance Company Name

Contract Type(s) Requested

Medicare Advantage HMO Medicare Advantage PPO Medicaid Commercial

Required Documents

You will receive a separate secure link for uploading.

Core Documents:

Current Professional License(s) - all states where practicing
DEA Certificate (if applicable)
CV/Resume (current)
Medical School Diploma
Residency/Fellowship Completion Certificate(s)
Board Certification Certificate(s)
Professional Liability Insurance (current face sheet/declarations page)
Voided Check or Bank Letter (for EFT setup)
W-9 Form
Government-issued Photo ID (Driver's License or Passport)

If Applicable:

Hospital Privileges Letter (if you have hospital affiliations)
Additional state licenses
Additional certifications or training certificates