Sole Practitioner Credentialing Form
Please be advised starting April 1, 2024, obtaining credential services will require completion of our POST & Claim It Documents Crash Course. This measure is to guarantee that you possess all the necessary documents for the credentialing process. A $10 fee applies.

Please answer all questions if not applicable indicate N/A.  Fees include health insurance portal set-up to verify patient's eligibility and claims status. Please be advised a Google Shared Folder will be created for you to upload required documents for this process, once payment is received.
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Email *
Practice Name *
Business Entity- Registered in your state. *
Required
Business Entity- Status *
Required
Your First and Last Name *
Date of Birth *
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What is your ethnicity? *
Do you speak any other languages besides ENGLISH? *
Social Security the first #-5 digits XXX-XX will retrieve the LAST FOUR DIGITS via CAQH platform.
Specialty in Healthcare *
Licensed issued in what state? *
License Number *
Practice Telephone Number *
Practice Fax Number
Practice Location Address 
***Include Zip code +4 digits***
 *
Practice Location County *
Business Effective Date (day you open your practice) *
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Business Website *
Business Email *
Do you have an AVAILITY LOGIN? *
Required
Availity Username & Password
Correspondence address  (letters, claim forms, etc). This can be your home address to ensure you receive important information. *
Is this a P. O Box address? *
Required
Tax ID Number *
Individual Provider Identification Number (NPI) = NPI 1 *
Group National Provider Identification Number (NPI) = NPI 2. Please be advised if you are seeking to get credentialed with Medicare, you must have a Group NPI #.
Name of your Electronic Medical Records System
(Required for Medicare Application)
 *
CAQH Username & Password (please make sure your ATTESTATION has been updated). *
CAQH Identification Number as Individual  *
Medicaid ID in your state (if applicable)
Medicare ID # (if applicable)
Please be advised if you are seeking to become a participating provider with Straight Medicaid or Medicare you or someone in your practice must have the CREDENTIAL(s) carriers recognize.
Your Credentials *
Required
Please specify other credential(s) *
ONLY APPLIES TO MD, NP, APN or PA, NPP- Are you affiliated with any hospitals? If yes, please indicated the name of each hospital.
ONLY APPLIES to Laboratory- Please upload CLIA CERTIFICATE document to the GOOGLE SHARED FOLDER.
List insurance carriers you are interested in becoming a Participating Provider. *
List insurance carriers you are currently credentialed with as an individual or through your employer.
Will you provide telehealth services? If yes, you must have a physical address- NO VIRTUAL ADDRESS or PO BOX. *
Required
Legal-Do you have any convictions, exclusions, revocations or suspensions within the last 10 years? *
Required
If yes, please indicate final adverse legal action date and action taken. If not applicable, please indicate N/A *
Please list your clinical practice expertise (depression, anxiety, substance abuse)? *
Location wheelchair accessible *
Required
Do you have an afterhours number or answering service for an emergency?  Besides patients to call 911.  If no, please obtain one to avoid credentialing process delays. *
Required
Do you have an afterhours number or answering service for an emergency?  If yes, please indicate the name of the answering service. *
Have you or your staff completed Cultural Competency Training? If yes, please indicate date and name of the training organization. *
Age Population *
Required
Days & Hours of Operations- Please indicate AM & PM and time zone (EST, Pacific). *
Are you interested in being a provider for Employee Assistance Program for carrier(s)? ***ONLY APPLIES TO MENTAL HEALTH PROVIDERS*****.
Are you interested in EFT (Electronic Funds Transfer)? If yes, a voided check will be required with your business name (NO PERSONAL ACCOUNTS or STARTER CHECKS) and a W9 form.  If you do not have a W9 form, P&C will complete on your behalf. Please upload voided check to the GOOGLE SHARED FOLDER.
Bank Address & Contact Number
Your signature is required for multiple documents. To avoid the back and forth.  Please put your signature on a blank sheet of paper (white). I will inform you if electronic signature is not accepted. Please upload signature document to the GOOGLE SHARED FOLDER.
Credentialing Service Fees- ONLY Commercial & Managed Care Plans
Straight Medicaid and/or Medicare Plan Credentialing Fees
Adding and/or Removing Providers from your Group Roster Fee Only
Terms & Conditions: POST & CLAIM, LLC will perform credentialing process for your business entity on your behalf. We will maintain open communication with you (provider) during this process. Effective January 3, 2024, to ensure open communication with the provider we request provider respond to P&C within 72 hours of receiving an email or text. If P&C does not receive a response back from the provider within the time frame stated, your services will be terminated - NO REFUND. If you would like to have services reinstated, there will be a $125 charge for services to be restored for each termination that occurs.
 A Google Shared Folder will be created to exchange documents (if additional documents are required). Joining health insurance carriers' network, each carrier credentialing process duration varies.  Please be advised the duration may take up to 90 days or longer.    If an application requires notary services or mailed, it will be your responsibility to have documents notarized and/or mailed.  Errors may occur during this process, any errors occur on behalf of P&C, will be corrected for resubmission to carrier. P&C will complete the application(s) and all correspondence will be directed to your business email address. Payments will only be accepted through our website postandclaim.com. All transactions are final NO REFUNDS.  If you have any further questions, please feel free to contact us at km@postandclaim.com or 551-253-3577. We look forward to working with you.
Signature Required *
Date *
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