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AC17 Provider Credentialing Application 3.docx

AC17 Provider Credentialing Application 3.docx 2025

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The document is a Provider Credentialing Application for AlohaCare, outlining the necessary steps and required documents for healthcare providers to join AlohaCare's network. It details the application process, including submission of professional licenses, insurance information, and personal demographics. The document emphasizes that providers must be credentialed before offering services to AlohaCare members and includes sections for health status, work history, and disclosure information as mandated by federal and state regulations.

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Click ‘Get Form’ to open the AC17 Provider Credentialing Application in the editor.
Begin by filling out the 'Identification and Demographics' section. Ensure you print in black ink, providing your legal name, title, and contact information accurately.
Complete the 'Provider Info' section, including your date of birth, social security number, and NPI. Be sure to select your gender and indicate if you provide EPSDT services.
Move on to 'Office Information/Location of Practice.' Specify whether this is your primary or additional location and fill in all relevant details about your practice.
In the 'State Licensure' section, list all licenses held in the last five years along with their expiration dates. Attach any necessary documentation.
Finally, review all sections for accuracy before submitting. Use our platform's features to save and share your completed application easily.

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2024	4.3 Satisfied (20 Votes)
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2009	4.5 Satisfied (32 Votes)

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What is an example of a credentialing?

An example of credentialing would be the physicians credentialing process, where a doctors medical degree, residency training, board certification, and state licensure are verified before they are allowed to treat patients at a hospital or medical facility.

What are credentialing applications?

- A credentialing process is utilized by health care facilities as part of its process to allow practitioners to. provide services on its campus, health plans to allow providers to participate in its network (provider enrollment), and other health care entities that have a need to hire or otherwise engage providers.

What is checked during a credentialing process?

The physician supplies the information required, including contact information, current CV, education and training history, licensing and certificates, medical group and hospital affiliations, Board certifications, sanctions or malpractice history, proof of liability insurance and peer references.

What comes first credentialing or privileging?

Hospitals and other health care employers and payers both have credentialing processes to complete. Credentialing is closely tied with privileging and is frequently a first step for physicians seeking hospital privileges.

What is the difference between credentialing and provider enrollment?

Provider enrollment is distinct from credentialing, although the two processes are often interrelated. While credentialing focuses on verifying the qualifications and competence of the provider, enrollment is about establishing the providers eligibility to bill a particular payer.

What is the Texas Administrative Code for credentialing?

Credentialing, as defined by Texas Administrative Code (TAC) 11.2(b)(17), is the process of collecting, assessing and validating qualifications and other relevant information pertaining to a physician or provider to determine eligibility to deliver health care services. The credentialing process is part of the

What is the purpose of credentialing?

Credentialing in healthcare is one of the first steps to a provider being able to practice. The rigorous process safeguards the integrity of the field, ensuring that only competent and qualified individuals are granted the privilege to provide care.