FACILITY INITIAL CREDENTIALING APPLICATION设施的初始认证的应用.docVIP

FACILITY CREDENTIALING APPLICATION INITIAL CREDENTIALING RECREDENTIALING Please read Instructions on Page 10 before completing. IDENTIFICATION CORPORATE IDENTIFICATION INFORMATION Legal Business Name: (As reported to the IRS) Federal Tax Identification Number (TIN): Doing Business As (DBA) Name: (If applicable) National Provider Identifier (NPI) for facility being credentialed: (Application cannot be processed without a valid 10-digit NPI) Corporate Address: City: State: Zip: Hospital or Health System Affiliation: Not affiliated with any hospital/health system Date of Incorporation: // Length of time in business with this Name and Tax ID: Years Months FACILITY INFORMATION Address must be a street address, not a Post Office box. Facility Name: Address Line 1: Address Line 2: City: State: Zip: County: Facility Phone: ()- Fax: ()- Website: www. Credentialing Contact Name: Contact Title: Phone: ()- Fax: ()- Email: Facility Administrator: Email: MAILING/CORRESPONDENCE ADDRESS Must be an address where provider can be contacted directly. PAYMENTS WILL BE MAILED TO THIS ADDRESS. Check here if all correspondence can be directed to the facility location above. If not, complete the section below. Name: Mailing Address Line 1: Mailing Address Line 2: City: State: Zip: Phone: :()- FACILITY TYPE Check ONE box only per Application. If your facility type is not listed below, do not complete and submit this application. MEDICAL Ambulatory Surgery Center – Free standing only Birth Center – Free standing only Must hold current, unconditional accreditation by CABC before a contract will be issued. Home Health Care Agency that provides skilled nursi