Provider Enrollment Credentialing Services — Credentialing & Contracting Intake

How this works: complete each section below, then click Export intake packet (top right) and send us the downloaded file, or submit this form as instructed by Provider Enrollment Credentialing Services. Use Save draft anytime to download your progress and Load draft to pick up where you left off. Nothing you type here is transmitted anywhere until you export and send it.

1Who is this intake for?

You are a solo practitioner enrolling yourself with payers.

How did you hear about us? *

Who referred you? (person or company name)

2Practice / Group information

Legal business name *

DBA / doing business as (if different)

Entity type *

Tax ID (EIN) *

Group NPI (Type 2) * (the organization's NPI — not any individual provider's)

Primary taxonomy / specialty of the group

Group Medicare PTAN (if enrolled)

Group Medicaid ID(s) (any state, if enrolled)

Primary service location

Street address *

Suite / unit

City *

State *

ZIP *

Additional service locations (one per line: street, city, state, zip)

Billing / correspondence

Billing / pay-to address (if different from service location)

Main phone *

Fax

Website

Authorized contact for this engagement

Contact name *

Title

Email *

Phone *

Our practice requires a Business Associate Agreement (BAA)
We'll send our standard mutual BAA for countersignature during onboarding.

2Your billing setup

How do you bill payers? *

Entity legal name

Entity type

EIN

Type 2 (group) NPI (if you have one)

Primary practice address (where you see patients) *

Billing / correspondence address (if different)

3Provider(s) to credential

Sensitive information notice: payers require each provider's Social Security Number and date of birth to process enrollment applications — but we deliberately do not collect them on this form. When your applications are being prepared, we'll request them through a secure, encrypted channel, enter them directly into the payer systems (CAQH, PECOS, Medicaid portals), and retain no copies. They are never stored in this intake packet or in our tracking system.

4Payer enrollment requests

Select every payer you want enrollment (or recredentialing) with. The initial package includes up to 6 payer applications per provider; each additional payer is $200 per application.

State(s) where you need enrollment *

Other / regional payers (comma-separated, e.g., your local BCBS name)

Target effective date / timing goals

Current participation & history (plans you're already in-network with, pending apps, prior terminations)

5Services requested

Initial credentialing & enrollment package — $1,500 per provider
CAQH setup/attestation + up to 6 payer applications per provider, managed to completion. Primary source verification bundle — $150 per provider
We confirm your license, education, and certifications directly with the issuing sources (licensing boards, schools, certification boards) — the verification standard payers and hospitals require — and provide documented evidence. Group onboarding — $500 one-time
Group entity setup: Type 2 NPI linkage, group payer records, roster management. Ongoing maintenance — $75 per provider / month
CAQH re-attestations, expirables tracking, revalidations, payer follow-ups — and for groups, a monthly roster review so provider additions and departures never slip through. Contract rate negotiation — $500 per successfully negotiated contract
When your payer contracts come through, we review the proposed fee schedule and negotiate for stronger rates (especially specialist codes). The fee applies only when a negotiation succeeds. Rate & fee-schedule maintenance — $50 per provider / month
Ongoing monitoring of your contracted rates: fee-schedule reviews, rate-change alerts, and a renegotiation calendar so your reimbursement never quietly erodes. Tax ID (EIN) procurement — $150 one-time
We prepare and file your IRS SS-4 as third-party designee and deliver your EIN — for new practices that don't have a Tax ID yet.

Estimated fees

Estimate only — assumes the same payer list for every provider. Your exact quote is confirmed in the service agreement before any work begins.

6Documents — file rules & anything extra

File rules for every upload on this form: PDF is preferred (it's what payers accept everywhere); clear photos or scans as JPG or PNG are also fine. Max 10 MB per file. Make sure the whole document is visible (all four corners), text is readable, and nothing is cut off or expired. You don't need originals — legible copies are what payers want.

Document upload boxes appear throughout the form next to the information they belong to. Anything you can't upload today, we'll request through a secure channel after intake — please don't email documents unencrypted. CAQH or portal passwords are never uploaded here; we collect login access separately through a secure channel.

Anything missing, expired, or on its way? (tell us here)

7Authorization & payment consent

(a) Authorization to act on your behalf. I authorize Provider Enrollment Credentialing Services to prepare, submit, and manage credentialing and payer enrollment applications for the provider(s) listed in this intake; to communicate with payers, CAQH, licensing boards, and verification sources on our behalf; and to receive application status information. Specifically, each provider agrees to: (a) add Provider Enrollment Credentialing Services as an authorized user on their CAQH profile (or grant equivalent access), (b) approve Provider Enrollment Credentialing Services's surrogacy request in the CMS Identity & Access (I&A) system so we can file and manage Medicare/PECOS applications on their behalf, and (c) approve access requests in payer portals (e.g., Availity) when prompted — we'll send simple step-by-step instructions for each. This authorization remains in effect for the duration of our engagement and may be revoked in writing at any time. (b) Payment terms. I understand that Provider Enrollment Credentialing Services operates fully digitally: one-time fees are invoiced via Stripe — ACH bank payment preferred, card accepted — and ongoing maintenance is billed as a monthly ACH autopay subscription. No paper checks are accepted. Work begins only after the service agreement is e-signed and autopay authorization is completed — both links will be sent after this intake is reviewed. (c) Accuracy. I certify that the information provided in this intake is true, complete, and current to the best of my knowledge, and I agree to promptly notify Provider Enrollment Credentialing Services of any changes (license status, address, malpractice coverage, adverse actions) during the engagement.

(d) Signature authorization — recommended. Credentialing regularly requires quick-turnaround signatures on routine forms (payer paperwork, e-signature requests) — often while you're with patients or traveling. Choose one:

I authorize Provider Enrollment Credentialing Services to apply my electronic signature to routine credentialing forms on my behalf when I'm unavailable. (Recommended — keeps your applications moving. Never used for payer contracts or anything creating new obligations without your review.) I prefer to sign everything myself. I understand this can add delays when a signature is needed and I'm not available.

Signature (type your full legal name) *

Title / credentials

Date *

Typing your name above constitutes your electronic signature on this intake. The formal service agreement follows separately for e-signature.

✓Finish

The intake packet contains no SSNs or dates of birth by design — it's safe to send by email and to import directly into the operations tracker.

Credentialing & Contracting Intake

1Who is this intake for?

2Practice / Group information

Primary service location

Billing / correspondence

Authorized contact for this engagement

2Your billing setup

3Provider(s) to credential

4Payer enrollment requests

5Services requested

Estimated fees

6Documents — file rules & anything extra

7Authorization & payment consent

✓Finish

Provider 1

Identity

Identifiers

State licenses

DEA & controlled substances (if prescribing)

Education & training

Work history — last 5 years

Malpractice insurance

Collaboration (NPs/PAs, in states that require physician collaboration or supervision)

Disclosures