Become a Network Provider | Ancillary Provider Credentialing Application

Application Received

Thank you. Our credentialing team will review your application and contact you within 5 business days at the email address you provided.

Questions? Call (800) 231-9311 or email info@healthcarecomp.com

Service Types

Check all service types your organization provides

Organization Information

Organization Name *

Office Address *

City *

State *

ZIP Code *

Phone *

Fax

Email *

Billing Information

Billing Contact Name *

Billing Address

Billing City

Billing State

Billing ZIP

Billing Phone

Billing Fax

Accreditation

Accrediting Agency Name

Accreditation Status

Accreditation Date

Expiration Date

Professional / General Liability Insurance

Insurance Company Name *

Policy Number *

Coverage Limits *

Carrier Phone

Questionnaire

If you answer Yes to any question, provide details in the field provided.

Question	Yes	No
Have criminal proceedings ever been initiated against your company or its authorized representatives?
Has your company ever been the subject of an investigation by state or federal authorities?
Has your company ever been suspended, sanctioned or restricted from participating in any private, state or federal health insurance program (e.g. Medicare or Medicaid)?
Has your company ever been denied accreditation/certification by Medicare or any accrediting organization?
Has your company ever been denied or canceled for professional liability insurance?
Has your company ever filed for bankruptcy?
Do you subcontract any services and if yes, are these providers accredited? If yes, please list which ones.

Details for any "Yes" answers above

Geographic Service Area

Select your primary service coverage

National Regional State Local

States / Regions Served

Quality Management Programs

Program	Yes	No
Patient Assessments
24 hour, 7 days/week coverage
In-service programs for all staff members
Maintain timely patient clinical records
Clinical records available for audit
Outcomes measurement system
Patient satisfaction surveys

Affirmation of Accuracy and Completeness

I affirm that information provided in or attached to this application is correct and complete. I understand that a condition of this application is that any misrepresentation or omission, whether intentional or not, is cause for automatic rejection.

Printed Name of Authorized Representative *

Title *

Date *

I affirm this information is accurate and complete *

Our credentialing team will review your application and contact you within 5 business days at the email address provided. Questions? Call (800) 231-9311.

Ancillary ProviderCredentialing Application