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Practitioner Credentialing Application Packet - Providers

Practitioner Credentialing Application Packet - Providers 2025

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The document is a comprehensive credentialing application for providers and practitioners seeking to participate in AlohaCare's health plans in Hawaii. It outlines the necessary forms, required documents, and important information regarding the enrollment process with the State of Hawaii's Department of Human Services. The application includes sections for personal information, professional qualifications, board certifications, licensure details, and disclosure questions related to any legal or disciplinary actions. It emphasizes the importance of complete and accurate submissions to avoid delays in the credentialing process.

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Click ‘Get Form’ to open the Practitioner Credentialing Application Packet in the editor.
Begin with Section A: Personal Information. Fill in your legal name, gender, date of birth, and contact details. Ensure all fields are completed accurately.
Proceed to Section B: Board Certification. Indicate your board specialties and certification dates. If not applicable, mark as N/A.
In Section C: Professional Licensure, list all active licenses along with their issue and expiration dates.
Complete Section D: Controlled Substances Certifications if applicable, providing necessary license numbers and effective dates.
Continue through Sections E to K, ensuring you provide all required information regarding professional liability coverage, work history, and compliance with nondiscrimination laws.
Review your entries for completeness before submitting the application. Use the checklist provided at the beginning of the packet to ensure all documents are included.

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Versions	Form popularity	Fillable & printable
2024	4.3 Satisfied (20 Votes)
2017	4.3 Satisfied (43 Votes)
2009	4.5 Satisfied (32 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What are the three types of credentialing?

The process entails verification and assessment of a physicians education, training and experience. It allows patients to trust that theyre in good hands and physicians to have trust in their peers. Credentialing also plays a part in physician health plan enrollment so that payment for services can be received.

What is the credentialing process for providers?

Healthcare providers must hold valid licenses and certifications to practice medicine legally in respective states or regions where a patient is receiving care. The credentialing process includes verifying the status of these licenses and ensuring they are current and unencumbered by restrictions or suspensions.

What is checked during a credentialing process?

Typical Credentialing Timelines On average, credentialing can take anywhere from 60 to 180 days, depending on factors like the complexity of the providers qualifications, the organization type, and specific payer requirements.

How much does credentialing cost per provider?

Initial credentialing setup costs for a solo practice provider may range from $200 to $500. Insurance panel applications cost $100 to $200, while database management costs $50 to $100 monthly.

What is the provider credentialing process?

Provider credentialing is a vetting process that verifies a healthcare providers qualifications, competency, and history. It ensures that clinicians are equipped to perform their roles effectively, whether they are conducting patient assessments, prescribing medications, or performing surgeries.