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New Provider Credentialing Request

If you are an existing client, please use this form to submit a new work request. DO NOT include sensitive information like SSN’s. Thank you!

Tell us what clinic you are with so we can identify you.

Please provide the name of someone we have on file with clinic that will be our primary point of contact for this request and whom will be updated as the request is processed.

Requested Project Start Date
On or before this date is when ClinicConnection will begin working on this work request. 2 weeks from today is our current scheduling window.

Provider List(Required)
First and Last Name
Work Email Address
CAQH #
Supporting Info
 
Provide names and contact email addresses of those Providers you need credentialed. Also provider supporting information like: The location, date of hire, and if they are a contractor or employee. Also let us know what insurance companies you would like us to cred them with. You can add more than one by selecting the PLUS (+) icon to the far right.

Supporting Data and Documents Assertion(Required)


Cancellation Policy(Required)