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Blank Caqh Provider Application PDF Template

The CAQH Provider Application Form serves as a standardized tool for healthcare providers to submit their professional and practice information to health plans and networks. It simplifies the process of credentialing by allowing providers to enter their details once and share them with multiple organizations. To streamline the completion of this critical form and avoid processing delays, providers are encouraged to follow the specific instructions provided, such as using the correct pen, printing legibly, and providing all required information. Click the button below to start filling out your CAQH Provider Application Form.

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Blank Caqh Provider Application PDF Template

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Embarking on the journey of becoming a healthcare provider involves an array of steps, among which the completion of the CAQH Provider Application form holds significant importance. This comprehensive document is crafted to gather detailed personal and professional information from healthcare providers, streamlining the process of credentialing and ensuring efficient provider data management. Its structure demands careful attention, requesting data ranging from basic personal information, including legal names and contact details, to more intricate professional identifiers such as National Provider Identification (NPI) numbers and state license information. The form also delves into the academic background of the applicant, capturing details about undergraduate, professional, and any post-graduate training, which collectively paints a vivid picture of the provider’s qualifications. Furthermore, sections dedicated to specialty certifications underscore the provider's areas of expertise, indicating their primary and secondary specializations alongside board certification statuses. Instructions embedded within the form guide the applicants on how to avoid common pitfalls that might delay the process, emphasizing the use of specific writing instruments and the importance of the legibility of the provided information. Succinctly, the CAQH Provider Application form is a pivotal tool in the healthcare industry, facilitating a smoother onboarding process for providers while ensuring that all pertinent information is correctly captured and formatted for use.

Preview - Caqh Provider Application Form

Provider Application

CAQH AUTOMATICALLY APPLIES MIXED-CASE FORMATTING,

CORRECT NUMBERS

CORRECT

INCORRECT

•

COMMON ABBREVIATIONS, AND ZIP CODE MATCHING. PLEASE

AND LETTERS

MARK

MARKS

MAKE CORRECTIONS ONLINE OR CALL THE HELP DESK.

Instructions

Tips to avoid processing delays

Read all instructions

Complete only this application and its supplemental forms. Do not use another provider’s application.

Use a blue or black ink ball-point pen only. Do not use a pencil or a felt-tip pen.

carefully prior to

Print legibly and inside the boxes provided based upon the examples given above.

submitting your

Do not enter more than 1 character per box. If necessary, write outside the provided spaces.

application.

Complete all sections that are applicable to you.

6. Some fields use “codes” to help you easily report information (e.g., schools, languages). Code lists are found on pages 36 - 43.

NOTE: Fields with asterisks (*) indicate that a response is required. All other fields will be considered not applicable if left blank.

SECTION 1

Personal Information and Professional IDs

Provider Type

Code list is found on page 36. Enter the

DO YOU PRACTICE EXCLUSIVELY WITHIN THE INPATIENT SETTING?*

associated 3-digit code in the space

YES

(E.G. PATHOLOGISTS, ANESTHESIOLOGISTS, ER PHYSICIANS, NURSE

provided.*

PRACTITIONER, RADIOLOGISTS, PHYSICIAN ASSISTANT, ETC.)

Name

Do not use nicknames

or initials, unless they

LAST NAME*

SUFFIX (JR, III)

are part of your legal

name.

FIRST NAME*

MIDDLE NAME

HAVE YOU EVER USED ANOTHER NAME?*

YES

IF YES, PLEASE LIST ALL OTHER NAMES USED AND THEIR DATES OF USE BELOW.

OTHER LAST NAME

SUFFIX (JR, III)

OTHER FIRST NAME

OTHER MIDDLE NAME

DATE STARTED USING OTHER NAME

DATE STOPPED USING OTHER NAME

General

Information

GENDER*

MALE

FEMALE

DATE OF BIRTH*

Only enter a Foreign

National Identification

Number if you do not

have a SSN. Do not

enter National Provider

CITY OF BIRTH

STATE OF

COUNTRY OF

Identification (NPI)

BIRTH

Number here.

SSN*

Code lists are found on

pages 36-43. Enter the

FOREIGN NATIONAL IDENTIFICATION NUMBER (FNIN)

FNIN COUNTRY OF ISSUE

associated 3-digit code

in the space provided.

ENTER ALL NON-ENGLISH

LANGUAGES YOU SPEAK

LANGUAGE CODE

Home Address

NUMBER

STREET

APT NUMBER

CITY

STATE

ZIP CODE

TELEPHONE

NOTE: CAQH will use

this method for

E-MAIL

application follow-up.

FAX

PREFERRED METHOD OF CONTACT*

E-MAIL

FAX

3076

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Page 01

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 1

Personal Information and Professional IDs (Continued)

Professional

IDs

FEDERAL DEA NUMBER

Include all state

DEA ISSUE DATE

licenses, DEA

Registration and State

Controlled Dangerous

DEA STATE OF REGISTRATION

DEA EXPIRATION DATE

Substance (CDS)

certification numbers.

Provide all current and

CDS CERTIFICATE NUMBER

CDS ISSUE DATE

previous licenses/

certifications.

CDS STATE OF REGISTRATION

CDS EXPIRATION DATE

Non-licensed

professionals should

enter certification/

registration number in

STATE LICENSE NUMBER

LICENSE ISSUING STATE

LICENSE ISSUE DATE

the space provided for

IF THIS IS A STATE LICENSE, ARE YOU

license number.

YES

CURRENTLY PRACTICING IN THIS STATE?

If you have additional

LICENSE EXPIRATION DATE

Professional IDs to

report, use the

Code list is found on page 36;

Professional IDs

use license status codes. Enter

use provider type codes. Enter

Supplemental Form on

3-digit code in space provided.

LICENSE STATUS CODE

page 19.

LICENSE TYPE

STATE LICENSE NUMBER

LICENSE ISSUING STATE

LICENSE ISSUE DATE

IF THIS IS A STATE LICENSE, ARE YOU

YES

CURRENTLY PRACTICING IN THIS STATE?

LICENSE EXPIRATION DATE

Code list is found on page 36;

use license status codes. Enter

use provider type codes. Enter

3-digit code in space provided.

LICENSE STATUS CODE

LICENSE TYPE

Other ID

ARE YOU A PART-

YES

Numbers

ICIPATING MEDICARE

PROVIDER?*

MEDICARE NUMBER

UPIN

If you have additional

ARE YOU A PART-

Professional IDs to

ICIPATING MEDICAID

YES

report, use the

PROVIDER?*

MEDICAID NUMBER

MEDICAID STATE

Professional IDs

Supplemental Form on

page 19.

NATIONAL PROVIDER IDENTIFICATION (NPI) NUMBER

USMLE NUMBER (WITHOUT HYPHENS)

WORKERS COMPENSATION NUMBER

—

ECFMG NUMBER (NON-U.S./CANADIAN GRADUATE ONLY)

ECFMG CERTIFICATE ISSUE DATE (NON-U.S./CANADIAN GRADUATE ONLY)

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Page 02

Section 2

Education and Training

Undergraduate

UNDERGRADUATE SCHOOL

School(s)

Provide the appropriate

information for the

OFFICIAL NAME OF UNDERGRADUATE SCHOOL

school that issued your

undergraduate degree

and all schools

attended.

ADDRESS

CITY

STATE

ZIP/POSTAL CODE

Professional

School(s)

Provide the appropriate

COUNTRY CODE

TELEPHONE

FAX

information for the

school that issued your

professional degree.

START DATE

END DATE (GRADUATION DATE)

DEGREE AWARDED

Fifth Pathway Graduates

DID YOU COMPLETE YOUR

YES

please complete the

UNDERGRADUATE EDUCATION

following sections: U.S.

AT THIS SCHOOL?

School that issued your

certificate, the Non-U.S.

GRADUATE TYPE*:

School where you

attended, and the Fifth

Pathway institution

U.S. OR CANADIAN GRADUATE

NON-U.S./CANADIAN GRADUATE

FIFTH PATHWAY GRADUATE

where you completed

your training on

U.S. OR CANADIAN SCHOOL

Supplemental Page 20.

Code lists are found on

SCHOOL CODE (U.S./

NAME OF U.S./

pages 36-43. Enter the

CANADIAN ONLY)

CANADIAN SCHOOL:

associated 3-digit code

in the space provided.

If you have additional

START DATE*

END DATE (GRADUATION DATE)*

DEGREE AWARDED

Undergraduate or

Professional Schools to

DID YOU COMPLETE YOUR

report, use the

GRADUATE EDUCATION AT THIS

YES

Education Supplemental

SCHOOL?

Form on page 20.

NON - U.S. OR CANADIAN SCHOOL

OFFICIAL NAME OF NON-U.S. PROFESSIONAL SCHOOL

ADDRESS

CITY

COUNTRY CODE

POSTAL CODE

START DATE*

END DATE (GRADUATION DATE)*

DEGREE AWARDED

DID YOU COMPLETE YOUR

YES

GRADUATE EDUCATION AT THIS

SCHOOL?

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Page 03

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Section 2

Education and Training (Continued)

Training

List all training

SCHOOL CODE (E.G.,

programs you

AFFILIATED MEDICAL

attended. Use one

SCHOOL)

section per institution.

INSTITUTION/HOSPITAL NAME (USE BOTH LINES IF REQUIRED)

If you have additional

post-graduate training

programs, use the

NUMBER

STREET

SUITE/BUILDING

Supplemental Training

Form on page 21.

Please explain on the

CITY

STATE

ZIP/POSTAL CODE

Supplemental

Professional / Work

History Gap Form on

page 33 any training

COUNTRY CODE

TELEPHONE

FAX

gap(s) of three (3)

months or greater, or

DID YOU COMPLETE THIS TRAINING PROGRAM AT THIS

YES

any gap(s) of a shorter

INSTITUTION?

duration if required by

(IF NOT, PLEASE USE THE SPACE BELOW TO EXPLAIN.)

the organization for

which you are being

credentialed.

Code lists are found on pages 36-43. Enter the associated 3-digit code in the space provided.

List each

INTERNSHIP/

FELLOWSHIP

OTHER

RESIDENCY

department

separately, if

START DATE

END DATE

applicable.

List

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

Internship/

Residency,

Fellowship

and Other

NAME OF DIRECTOR

programs

separately.

INTERNSHIP/

FELLOWSHIP

OTHER

RESIDENCY

START DATE

END DATE

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

NAME OF DIRECTOR

INTERNSHIP/

RESIDENCY

FELLOWSHIP OTHER M M Y Y Y Y M M Y Y Y Y

START DATE

END DATE

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

NAME OF DIRECTOR

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Section 3

Professional / Medical Specialty Information

Primary

SPECIALTY

INITIAL

DO YOU WISH TO

HMO

YES

Specialty

CODE

CERTIFICATION

BE LISTED IN

DATE

THE DIRECTORY

RECERTIFICATION

UNDER THIS

Code lists are found on

BOARD

YES

SPECIALTY?

PPO

YES

DATE

CERTIFIED?

pages 36-43. Enter the

(IF APPLICABLE)

associated 3-digit code

CERTIFYING

EXPIRATION DATE

in the space provided.

POS

YES

BOARD

(IF APPLICABLE)

CODE

IF NOT

I HAVE TAKEN

I INTEND TO SIT FOR AN

I DO NOT INTEND TO TAKE

BOARD

EXAM, RESULTS

EXAM ON

A CERTIFYING BOARD EXAM.

CERTIFIED

PENDING FOR

(SELECT

ONE)

CERTIFYING BOARD CODE

IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE A CERTIFYING BOARD EXAM, PLEASE USE THE

FOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.

Secondary

SPECIALTY

INITIAL

DO YOU WISH TO

HMO

YES

Specialty

CODE

CERTIFICATION

BE LISTED IN

DATE

THE DIRECTORY

RECERTIFICATION

UNDER THIS

Code lists are found on

BOARD

YES

SPECIALTY?

PPO

YES

DATE

CERTIFIED?

pages 36-43. Enter the

(IF APPLICABLE)

associated 3-digit code

CERTIFYING

EXPIRATION DATE

in the space provided.

POS

YES

BOARD

(IF APPLICABLE)

CODE

If you have additional

IF NOT

I HAVE TAKEN

I INTEND TO SIT FOR AN

Professional / Medical

I DO NOT INTEND TO TAKE

BOARD

EXAM, RESULTS

Specialties to report,

EXAM ON

A CERTIFYING BOARD EXAM.

CERTIFIED

PENDING FOR

use the Additional

(SELECT

Specialties

ONE)

Supplemental Form on

page 22.

CERTIFYING BOARD CODE

IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE A CERTIFYING BOARD EXAM, PLEASE USE THE

FOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.

3081

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Page 05

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 3

Professional / Medical Specialty Information (Continued)

Certifications

Do you hold the following certifications? If yes, provide expiration dates.

EXPIRATION DATE

BASIC LIFE

ADV LIFE

YES

SUPPORT IN

YES

SUPPORT?*

OB?*

ADV TRAUMA

CPR?*

YES

LIFE

YES

SUPPORT?*

ADV

PEDIATRIC

CARDIAC

YES

ADVANCED

YES

LIFE SPT?*

NEONATAL

ADVANCED

YES

LIFE SPT?*

Practice

Interests

Provide additional

areas of professional

practice interest,

activities, procedures,

diagnoses or

populations.

Primary

Credentialing

Contact

LAST NAME

CHECK HERE TO

USE THE OFFICE

FIRST NAME

M.I.

MANAGER AND

ADDRESS OF THE

PRIMARY PRACTICE

LOCATION AS THE

NUMBER

STREET

SUITE/BUILDING

CREDENTIALING

INFORMATION.

CITY

STATE

ZIP CODE

NOTE:

Even if you checked

TELEPHONE

FAX

the boxes above,

please provide the

e-mail address, if

E-MAIL ADDRESS

available.

3082

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*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information

Primary

NOTE: IF YOU INDICATED THAT YOU PRACTICE EXCLUSIVELY WITHIN THE INPATIENT SETTING ON PAGE 1, YOU ARE ONLY REQUIRED TO COMPLETE THE

Practice

CREDENTIALING CONTACT QUESTION ABOVE. SECTION 4 MAY BE LEFT BLANK. YOU MAY PROCEED TO SECTION 5 ON PAGE 11.

Location

CURRENTLY

YES

IF NO, WHAT IS

PRACTICING AT

YOUR EXPECTED

THIS ADDRESS?*

START DATE?

If you have additional

practice locations, use

the Supplemental

PHYSICIAN GROUP / PRACTICE NAME TO APPEAR IN DIRECTORY (DO NOT ABBREVIATE)*

Practice Location

Information Form on

pages 25-29.

GROUP / CORPORATE NAME AS IT APPEARS ON W-9, IF DIFFERENT FROM ABOVE (DO NOT ABBREVIATE)

NOTE: “General

Correspondence” refers

to any correspondence

NUMBER*

STREET*

SUITE/BUILDING

that might be sent to the

provider that does not

solely relate to creden-

CITY*

STATE*

ZIP CODE*

tialing or billing

information.

SEND GENERAL

YES

CORRESPON-

TIP Your Individual Tax

DENCE HERE?*

TELEPHONE*

FAX

ID is assumed to be

your Primary Tax ID

unless you specify

otherwise to the right.

OFFICE E-MAIL ADDRESS

PRIMARY

USE INDIVIDUAL

USE GROUP

TAX ID

(ONE ONLY)*

INDIVIDUAL TAX ID

GROUP TAX ID

Office Manager

or Business

Office Staff

LAST NAME*

Contact

List each contact

FIRST NAME*

M.I.

separately. You may

use the check boxes

below for convenience.

TELEPHONE*

FAX

Do not write

instructions like “see

above”. These

responses will be

E-MAIL ADDRESS

rejected and will

require follow-up.

Billing Contact

LAST NAME*

CHECK HERE TO

USE OFFICE

MANAGER AND

OFFICE ADDRESS

FIRST NAME*

M.I.

AS BILLING

INFORMATION

NUMBER*

STREET*

SUITE/BUILDING

NOTE:

Even if you checked

CITY*

STATE*

ZIP CODE*

the box above, please

provide the

E-mail Address of the

TELEPHONE*

FAX

Billing Contact.

E-MAIL ADDRESS

3083

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Page 07

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information (Continued)

Payment and

ELECTRONIC

YES

Remittance

BILLING

CAPABILITIES?*

BILLING DEPARTMENT (IF HOSPITAL-BASED)

YOUR “CHECK PAYABLE TO”

INFORMATION SHOULD BE

CONSISTENT WITH YOUR

W-9.

CHECK PAYABLE TO*

CHECK HERE TO

USE OFFICE

MANAGER AND

OFFICE ADDRESS

LAST NAME*

AS PAYEE

INFORMATION

FIRST NAME*

M.I.

NUMBER*

STREET*

SUITE/BUILDING

NOTE:

Even if you checked

CITY*

STATE*

ZIP CODE*

the box above, please

provide the

E-mail Address of the

TELEPHONE*

FAX

Payee Contact.

E-MAIL ADDRESS

Office Hours

(USE HHMM FORMAT AND ROUND TO THE NEAREST HALF-HOUR)

START

A=AM

END

A=AM

START

A=AM

END

A=AM

P=PM

MONDAY

FRIDAY

TUESDAY

SATURDAY

WEDNESDAY

SUNDAY

NOTE:

THURSDAY

After hours back office

telephone will be used

only by the health plan

24/7 PHONE COVERAGE?*

IF YES

AFTER HOURS BACK OFFICE TELEPHONE

and will not be

ANSWERING

VOICE MAIL WITH

VOICE MAIL

published under any

YES

INSTRUCTIONS TO CALL

WITH OTHER

SERVICE

circumstances.

ANSWERING SERVICE

INSTRUCTIONS

Open Practice

ACCEPT NEW PATIENTS INTO THIS PRACTICE?*

YES

ACCEPT ALL NEW PATIENTS?*

YES

Status

ACCEPT EXISTING PATIENTS WITH CHANGE OF PAYOR?*

YES

ACCEPT NEW MEDICARE PATIENTS?*

YES

ACCEPT NEW PATIENTS WITH PHYSICIAN REFERRAL?*

YES

ACCEPT NEW MEDICAID PATIENTS?*

YES

IF ANY OF THE

ABOVE INFORMATION

VARIES BY PLAN,

EXPLAIN (USE BOTH

LINES IF REQUIRED)

ARE THERE ANY

GENDER LIMITATIONS

AGE LIMITATIONS

LIST OTHER LIMITATIONS

PRACTICE LIMITATIONS?*

MALE

MINIMUM

ONLY

NONE

AGE

YES

IF YES

FEMALE

MAXIMUM

ONLY

AGE

3084

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Page 08

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information (Continued)

Mid-Level

DO MID-LEVEL PRACTITIONERS (NURSE PRACTITIONERS, PHYSICIAN

YES

ASSISTANTS, ETC.) CARE FOR PATIENTS IN YOUR PRACTICE?*

Practitioners

(IF YES, PLEASE PROVIDE THE INFORMATION BELOW)

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

3085

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Page 09

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information (Continued)

Languages

LANGUAGES

NON-ENGLISH LANGUAGES

Code lists are found on

SPOKEN BY OFFICE PERSONNEL

pages 37. Enter the

LANGUAGE CODE

associated 3-digit code

in the space provided.

INTERPRETERS

YES

LANGUAGES

AVAILABLE?*

INTERPRETED

LANGUAGE CODE

Accessibilities

DOES THIS OFFICE MEET ADA ACCESSIBILITY REQUIREMENTS?*

YES

DOES THIS SITE OFFER HANDICAPPED

DOES THIS SITE OFFER OTHER

YES

ACCESSIBLE BY

YES

ACCESS FOR THE FOLLOWING

SERVICES FOR THE DISABLED?*

PUBLIC TRANSPORTATION?*

YES

BUS*

YES

BUILDING?*

TEXT TELEPHONY (TTY)*

YES

PARKING?*

YES

AMERICAN SIGN LANGUAGE*

YES

SUBWAY*

MENTAL/PHYSICAL IMPAIRMENT

REGIONAL TRAIN*

YES

RESTROOM?*

YES

SERVICES*

OTHER HANDICAPPED ACCESS

OTHER DISABILITY SERVICES

OTHER TRANSPORTATION ACCESS

Services

Does this location provide any of the following services?

LABORATORY

IF YES, PROVIDE ACCREDITING/

YES

CERTIFYING PROGRAM

SERVICES?

(E.G., CLIA, COLA, MLE)

RADIOLOGY

YES

IF YES, PROVIDE X-RAY

SERVICES?

CERTIFICATION TYPE

EKGS?

YES

ALLERGY

YES

ALLERGY SKIN

YES

ROUTINE OFFICE

YES

GYNECOLOGY

INJECTIONS?

TESTING?

(PELVIC/PAP)?

AGE

DRAWING

YES

FLEXIBLE

YES

TYMPANOMETR

YES

BLOOD?

APPROPRIATE

Y/ AUDIOMETRY

IMMUNIZATIONS?

SIGMOIDOSCOPY?

SCREENING?

ASTHMA

YES

OSTEOPATHIC

YES

IV HYDRATION/

YES

CARDIAC

YES

TREATMENT?

MANIPULATION?

TREATMENT?

STRESS TEST?

PULMONARY

YES

PHYSICAL

YES

CARE OF MINOR

YES

FUNCTION

THERAPY?

LACERATIONS?

TESTING?

IF YES, WHAT

IS ANESTHESIA

ADMINISTERED IN

YES

CLASS/CATEGORY

YOUR OFFICE?

DO YOU USE?

IF YES, WHO

ADMINISTERS IT?

LAST NAME

FIRST NAME

TYPE OF PRACTICE

SOLO PRACTICE

SINGLE SPECIALTY GROUP

MULTI-SPECIALTY GROUP

(SELECT ONE ONLY)*

ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)

3086

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Page 10

Download Caqh Provider Application PDF Form

Form Data

Fact Name	Description
Form Purpose	The CAQH Provider Application form is designed to standardize and simplify the process of credentialing for healthcare providers.
Formatting Rules	Automatic mixed-case formatting, numerical corrections, common abbreviations, and zip code matching are applied to the application to ensure accuracy.
Writing Instructions	Applicants are instructed to use blue or black ink and to print legibly in the boxes provided, following specific formatting examples.
Submission Requirements	Providers must complete all applicable sections of the application, using only this form and its supplemental forms for their submission.
Code Lists for Fields	Some fields require the use of specific "codes" to report information such as schools and languages, with lists provided on the form for reference.
Professional Identification	Section 1 of the application collects personal and professional identification information, including details about licenses and certifications.

Instructions on Utilizing Caqh Provider Application

Filling out the CAQH Provider Application requires meticulous attention to detail and a systematic approach to ensure the accuracy and completeness of the information provided. This process is designed to facilitate a smoother credentialing experience by standardizing the way provider data is collected and processed. Prior to beginning the task, gather all necessary documents, such as professional licenses, DEA/CDS certifications, education and training certificates, and any other identifiers that will be needed to complete the application. The following steps are crafted to simplify the process of filling out the application, aiming to avoid common errors and processing delays.

Before filling out the form, carefully read all the instructions provided to familiarize yourself with the requirements and avoid any mistakes that could lead to processing delays.
Use only a blue or black ink ball-point pen to complete the application. Other writing instruments are not acceptable and could result in processing issues.
Ensure that all entries are legible and written within the provided boxes, adhering to the mixed-case formatting and correct numerical order as specified in the instructions. Use one character per box and, if necessary, utilize the space outside the provided boxes judiciously.
Fill out every section of the application that is applicable to your professional and personal status. Be mindful that fields marked with an asterisk (*) are mandatory and require a response.
For sections that require coded responses (such as professional type codes or language codes), refer to the code lists provided on pages 36 through 43 of the application instructions to accurately complete these fields.
Under the Section 1 "Personal Information and Professional IDs," provide all requested details such as your full legal name, any aliases previously used, contact information, and professional identifiers. Remember, your name should not include nicknames or initials unless they are part of your legal name.
In the "Professional IDs" subsection, include your Federal DEA number, state license numbers, and any other relevant identification numbers, ensuring to also report the issue and expiration dates for each.
Proceed to Section 2 "Education and Training," inputting detailed information about your undergraduate and professional education, including the start and end dates, the degrees awarded, and the institutions attended.
For the "Training" part of Section 2, list all residency, internship, fellowship, or other training programs, including important details such as the program director's name and the training program's duration and specialty.
Within Section 3 "Professional / Medical Specialty Information," provide information about your primary and secondary specialties, including certification dates and the certifying board codes, which can be found in the code lists.
If applying for multiple specialties or have additional professional IDs that were not included in the main sections of the form, use the supplemental forms provided on page 19 for Professional IDs and page 22 for Specialties.

Once the application is thoroughly reviewed and all sections are accurately completed, double-check the form for any missed entries or potential errors. Submit the completed application as directed, along with any supplemental forms or documentation that may be required. The successful submission of your application is the first crucial step towards credentialing, opening the door to professional opportunities and partnerships in the healthcare field.

Obtain Answers on Caqh Provider Application

What is the CAQH Provider Application and who needs to complete it?
The CAQH Provider Application is a standardized form used by healthcare providers to submit their professional and practice information to health plans, hospitals, and other healthcare organizations for credentialing purposes. It is designed to simplify the process of gathering and verifying a provider's data by offering a centralized database that can be accessed by multiple entities. This form is necessary for any healthcare professional, such as doctors, dentists, nurse practitioners, and others, who seek to be credentialed to practice in a healthcare setting or to join a health plan's network.
Which sections of the CAQH Provider Application must be filled out?
- All applicable sections based on the provider's specific circumstances must be completed. These include personal information, professional IDs, education and training, as well as information on professional/medical specialties. Special attention should be given to fields marked with an asterisk (*), as these responses are required. Leaving these fields blank may cause processing delays and necessitate follow-up.
- It's important to use a blue or black ink ball-point pen and print legibly inside the boxes provided. Make sure not to enter more than one character per box and fill out all the relevant sections completely.
How can I avoid delays in the processing of my CAQH Provider Application?
To prevent delays, first, ensure that all required fields marked with an asterisk (*) are completed. Use blue or black ink for filling out the form and print legibly within the designated spaces. Enter information accurately, based on the examples provided, and utilize the correct numbers, letters, and abbreviations as indicated. Moreover, avoid using nicknames or initials unless they are part of your legal name. Lastly, if errors are spotted or corrections are needed, it is advisable to make these changes online or by contacting the help desk directly.
Can I use a digital format to submit the CAQH Provider Application or must it be handwritten?
While specific submission methods can vary by the requesting organization (e.g., a health plan or healthcare provider group), the CAQH Provider Application typically allows for electronic submission through CAQH's online platform. Utilizing mixed-case formatting, common abbreviations, and zip code matching, the system is designed to ensure data accuracy and integrity. Providers are encouraged to complete the application online, which can be more efficient and can help reduce the risk of errors inherent in handwritten forms. If unsure, providers should check with the entity requesting their application for specific submission guidelines.

Common mistakes

When filling out the CAQH Provider Application form, individuals often make several mistakes that can delay the process. Recognizing and avoiding these mistakes is crucial for a smooth and efficient application process. Below are nine common mistakes:

Using the wrong writing tool - Applicants sometimes use a pencil or a felt-tip pen instead of the required blue or black ink ball-point pen.
Filling out the application illegibly or outside the designated boxes, despite instructions specifying to print legibly and inside the boxes.
Entering more than one character per box or writing outside the provided spaces, which goes against the application guidelines.
Not completing all applicable sections. The application includes instructions to fill out every section that pertains to the applicant's situation.
Leaving fields blank or not using the provided “codes” for easier reporting of information such as schools and languages, where code lists are provided to facilitate accurate completion.
Failure to include essential personal information, such as legal names without nicknames or initials unless they are part of the legal name as required on the form.
Incorrectly identifying provider type and not entering the associated three-digit code for provider type and other coded information.
Omitting previous or other names used, which is a critical component for background checks and verification processes.
Providing incomplete Professional IDs, such as leaving out state DEA licenses, DEA Registration, and Controlled Dangerous Substance certification numbers.

To mitigate these common errors, applicants are encouraged to:

Thoroughly read all instructions before filling out the form.
Ensure all information is provided in the correct format using the specified writing tool.
Double-check that all applicable sections are completed accurately and in full.
Utilize the code lists provided between pages 36 - 43 for correct code entries.
Regularly save progress if completing online and make corrections as needed before submission.

By paying close attention to these details, applicants can avoid unnecessary delays in the processing of their CAQH Provider Application form.

Documents used along the form

When submitting the CAQH Provider Application Form, it's essential to ensure that all necessary documents accompany your application to avoid delays in the processing and verification of your professional credentials. Among the range of required forms and documents, several key items should be prepared and double-checked for accuracy and completeness. Here is a list of nine commonly needed documents that often accompany the CAQH Provider Application Form:

Curriculum Vitae (CV): A comprehensive account of your education, work history, professional affiliations, publications, and other academic accomplishments.
State Medical License: Proof of your current state medical license, highlighting your eligibility to practice medicine within the state.
Board Certification: Document verifying your board certification status in your specialty, essential for showcasing your expertise and qualifications.
Drug Enforcement Administration (DEA) Certificate: Essential for practitioners prescribing medications, the DEA certificate verifies your authority to prescribe controlled substances.
Professional Diploma(s): Your medical school diploma and any other graduate or postgraduate diplomas, which serve as proof of your educational background.
Professional Liability Insurance Certificate: This document provides evidence of your current malpractice insurance coverage, detailing policy limits and the coverage period.
Continuing Medical Education (CME) Certificates: Documentation of completed CME activities is required to demonstrate ongoing professional development and compliance with licensure requirements.
Malpractice Claim History: A summary of any malpractice claims made against you, including dates, outcomes, and details of the incidents.
Federal National Practitioner Identifier (NPI) Documentation: Proof of your NPI number, which is necessary for processing billing and identifying providers in healthcare transactions.

Accurately preparing and submitting these documents along with your CAQH Provider Application Form is critical for a smooth credentialing process. Each document plays a vital role in verifying your qualifications, legal compliance, and professional standing in the medical community. Hence, thorough attention to detail in compiling and reviewing these documents before submission cannot be overstated.

Similar forms

The Universal Credentialing DataSource form also standardizes the process for providers to submit their professional and practice information for credentialing purposes. It likewise emphasizes factual accuracy and completeness to avoid processing delays.
The Medical Licensure Application used by state medical boards shares similarities in requiring detailed personal, educational, and professional experience. Both applications demand precision in filling out to avoid errors or omissions that could impact licensure or credentialing.
The National Provider Identifier (NPI) Application collects provider details for a unique identifier. Although this form focuses specifically on obtaining an NPI, both require accurate personal and professional identification details.
A Professional Liability Insurance Application asks for detailed professional information, similar to the CAQH application, to evaluate the risk and coverage terms for a provider. Both necessitate thorough history documentation to process the application effectively.
Hospital Privilege Application forms, which physicians must fill out to get admitting privileges, require similar detailed professional and educational information, along with a history of professional credentials and any disciplinary actions.
A DEA Registration Application for controlled substances prescribing authority demands specific personal and professional details, akin to the CAQH form, to ensure only qualified providers are granted this privilege.
The Board Certification Application for medical specialists shares the need for detailed education, training, and professional practice information to establish a provider’s qualifications in a specialty area.
State Controlled Dangerous Substances (CDS) Certification Application requires personal and professional information, including details about licensure and DEA registration, to authorize providers to handle controlled substances within state boundaries.
The Medicare Enrollment Application for physicians and other eligible professionals requires detailed personal, educational, and professional information to assess eligibility for participation in the Medicare program.
Medicaid Provider Enrollment Application varies by state but similarly requires extensive details about the provider's qualifications, practice history, and professional credentials for participation in Medicaid.

Dos and Don'ts

Filling out the CAQH (Council for Affordable Quality Healthcare) Provider Application form is a critical step for healthcare providers to participate in various insurance networks. It may seem like a straightforward task, but a few missteps can delay your application's approval. Here's a guide to things you should and shouldn't do when completing the form:

Do's:

Do read all instructions before starting the application. This may seem obvious, but it’s easy to overlook key details that could lead to mistakes.
Use a blue or black ink ball-point pen if you're filling out the form by hand. The clarity and permanence of these inks make your application easy to read and official.
Print legibly and stay within the boxes provided for your answers. If the information is hard to read or misplaced, it could delay processing.
Complete all sections applicable to you, ensuring you provide comprehensive information about your qualifications and experience.
Refer to the code lists on pages 36 - 43 for accurate information. These codes help standardize the entries and facilitate smoother processing.
Make sure to enter a response in all fields marked with an asterisk (*), as these are mandatory. Leaving them blank will result in processing delays.
Review your application thoroughly before submission. Ensure all information is correct and complete to avoid follow-up queries or delays.

Don'ts:

Don't use another provider's application as a template for your own. Each application is unique and should be completed based on your personal and professional information.
Don't use pencil or felt-tip pens, as these can smudge or fade, making your application hard to read.
Don't enter more than 1 character per box unless necessary. If you run out of space, use the additional space provided or attach a supplement.
Don't leave applicable sections incomplete. If a section applies to you, provide complete information to avoid processing delays.
Don't guess on codes or information. If you’re unsure, take the time to look up the correct codes or information to ensure accuracy.
Don't submit without checking for errors or incomplete information. An application with mistakes or missing details will likely be returned or delayed.
Don't forget to sign and date your application. An unsigned application cannot be processed.

Taking the time to carefully complete the CAQH Provider Application can streamline the credentialing process and enable you to participate in insurance networks more quickly. Attention to detail and adherence to the do's and don'ts outlined above can significantly impact the success of your application.

Misconceptions

When navigating the complexities of the Council for Affordable Quality Healthcare (CAQH) Provider Application process, several misconceptions can complicate what should be a straightforward procedure. Dispelling these myths not only facilitates a smoother application experience but also ensures that healthcare providers can expedite their path toward credentialing and patient care. Here is a clarification of six common misconceptions:

Using another provider's application is acceptable for efficiency. This is incorrect. Each provider must complete their unique application and supplemental forms. Utilizing another provider's application undermines the accuracy and integrity of your professional profile, potentially delaying the processing time.
All writing instruments are suitable for completing the form. This notion is false. The application instructions explicitly state that only blue or black ink ball-point pens are to be used. Other writing tools, like pencils or felt-tip pens, might render the application illegible or unfit for processing, leading to unnecessary delays.
It’s permissible to fill in more than one character per box. This practice is advised against. Adhering to the one character per box guideline, based on the examples provided, ensures clarity and prevents errors in data entry that could hinder application processing.
Completing all sections is necessary. This statement isn't entirely accurate. Applicants are encouraged to complete only the sections relevant to their practice and qualifications. Inapplicable sections left blank will not adversely affect the application, streamlining the process by focusing only on relevant information.
Fields marked with asterisks are optional. This is a misconception. Fields marked with asterisks (*) signify required information. Failure to respond to these prompts may result in processing delays and necessitate follow-up, prolonging the credentialing process.
Personal stories and explanations are unnecessary. On the contrary, providing detailed accounts, particularly in sections where explanations are requested (e.g., gaps in professional history or choice not to take a board exam), is crucial. These narratives offer context that can be vital for understanding a provider's background, ultimately facilitating the application’s approval without undue follow-up.

Clearing up these misconceptions ensures healthcare providers are better informed and prepared when completing the CAQH Provider Application. By adhering to the specified guidelines and understanding what is expected in each section of the form, providers can contribute to a more streamlined, efficient credentialing process, paving the way for a quicker transition to delivering patient care.

Key takeaways

Filling out the CAQH Provider Application form accurately and comprehensively is essential for healthcare providers. The following are key takeaways to help ensure that the process goes smoothly:

Use the correct application form. It is important to complete this specific application and its supplemental forms, as using another provider’s application can lead to delays.
Choose the right writing tool. Only blue or black ink ball-point pens should be used for this application. Pencils or felt-tip pens are not acceptable as they may cause legibility issues.
Ensure clarity and accuracy. Printing legibly and within the provided boxes, based on the provided examples, helps in avoiding misunderstandings or data entry errors.
Adhere to the one character per box rule. If more space is needed, it’s advised to write outside the provided spaces while still keeping the information as clear as possible.
Complete all applicable sections. It is crucial to fill in all sections relevant to your practice, as incomplete applications can result in processing delays.
Use codes where required. Some fields require codes, such as for schools or languages. The code lists provided on specific pages of the application assist in this process.
Do not leave required fields blank. Fields marked with asterisks (*) require a response. Not providing a response can cause significant delays and necessitate follow-up communication.
Professional ID numbers are critical. Including all state DEA licenses, DEA Registration, State Controlled Dangerous Substance (CDS) certification numbers, and other professional IDs as applicable, is essential for the application process.

Adhering to these guidelines not only facilitates a more efficient application process but also ensures that the provider’s information is accurately and effectively processed, minimizing delays and the need for additional follow-up.

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