CHL Credentialing Form 2025

1. Click ‘Get Form’ to open the CHL Credentialing Form in the editor.
2. Begin with Section 1: Personal Information. Fill in your name, home address, telephone number, birth date, and Social Security number. Ensure all details are accurate.
3. Move to Section 2: Education Information. List your educational background, including school names and degrees awarded. Attach a copy of your highest degree.
4. In Section 3: Licensure, provide details of all current professional licenses along with copies. Include any past licenses that are no longer active.
5. Complete Section 4: Admitting Privileges if applicable by listing hospitals where you have privileges.
6. Proceed to Section 5: Registrations and Certifications. Indicate any certifications you hold and attach relevant copies.
7. Fill out Section 6: Paneling/Credentialing by listing Managed Care panels you've served on and attaching necessary documents.
8. In Section 8: Questionnaire, answer all questions honestly. If you answer 'yes' to any question, provide explanations as required.
9. Finally, review all sections for accuracy before signing in Section XI: Verification to confirm the information is complete and correct.

Start filling out your CHL Credentialing Form today for free using our platform!