Credentialing request form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section I, 'Requestor Information.' Fill in your name, title, and email address where you want the application sent. Ensure the date is completed accurately.
3. Proceed to Section II, 'Practitioner Demographics.' Enter the practitioner's first and last name, middle initial, professional designation, and select their gender. Complete all required fields marked with an asterisk (*), including DOB and Social Security Number.
4. In Section III, 'Practice Information,' provide details about the practice such as name, address, city, state, phone number, fax number, and zip code.
5. Finally, in Section IV, 'Facility Requests,' indicate any changes needed for facilities associated with the practitioner. Select 'Add' or 'Remove' as necessary for each facility listed.
6. Once all sections are filled out correctly, save your changes and email the completed form to the appropriate Credentialing Coordinator based on your state.

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