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Advocate Credentialing Solutions
Provider Intake Form
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* Indicates required question
Email
*
Your email
Please answer each question completely as this is the information that will be referenced when completing applications for credentialing.
Name(First Name Last Name)
*
Your answer
Business Name
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Phone Number
*
Your answer
Organization Email
*
Your answer
Do you have a website? (Enter website address below)
Your answer
Are you a lab owner?
*
Yes
No
Required
If you are a lab owner, are you mobile or a brick and mortar building?
*
Mobile (you perform tests outside of your base of operations)
Brick and Mortar (you perform tests at your place of business)
Both (you perform tests both in your business and outside of your business)
I'm not a lab owner
Which insurance/payment service would you like to be credentialed for?
*
HRSA (OptumPay)
Medicaid
Medicare
Other Insurance
I will need billing
Other:
Required
Please select the items you have available to complete your provider enrollment application.
These documents are necessary to complete provider enrollment.
Credentialing Checklist
*
Form SS-4 (EIN Letter from the IRS)
Business License or Other Business Formation Document
W-9 Form
Proof of Business Bank Account (Voided Check or Bank Letter)
CLIA Certificate/ Number
NPI Number
I don't have any of these documents (will require a $15 consultation to assist)
Required
Do you agree to allow Advocate Credentialing Solutions to act on your organization's behalf to complete enrollment? (Service agreement to follow)
*
Yes
No
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