New Client Intake

Individual Provider Information Data Intake Form

Complete all sections below to begin the credentialing process. Your information is encrypted and stored securely.

Healthcare provider credentials and licensing

Provider Full Legal Name

Individual NPI (Type 1)

Provider SSN

Provider Date of Birth

Professional License Number

DEA Registration Number

Board Certification

Professional Liability Insurance Carrier

CAQH Provider ID

CAQH Login ID

CAQH Password

PECOS (Medicare) Login

User ID

Password

Medicaid State Portal Login

User ID

Password

Availity Essentials Login

User ID

Password

UnitedHealthcare (UHC) / Optum ID

User ID

Password

Upload all required documentation

Please Upload in PDF, Jpeg, PNG Format Only.

IRS CP-575 or 147C Letter

W-9 Form

Certificate of Liability Insurance (COI)

Business License

Company Letterhead

Current CV / Resume

Professional State License

DEA Certificate

Board Certification

Driver's License