Provider Re-Credentialing Form

*Required field.

Please check one of the following:*

Recredentialing Application

Please check one of the following:*

Physician Advanced Practice Provider

Applicant Name*

First Name

Last Name

Suffix (optional)

Degree*

Date of Birth*

Social Security Number*

NPI Number*

Provider Personal Email*

Health Partners communicates pertinent information via email. This email address is NOT shared with patients. The applicant's unique email address must belong to him/her specifically and must not be the office manager.

Provider Cell Phone*

Must be the applicant's cell phone and not the credentialing contact.

Practice Name*

If the Practice Name above is "Mount Carmel" then please also check the box below

Mount Carmel

Tax ID Number*

Start Date with Group*

Credentialing Contact Name*

First Name

Last Name

Credentialing Contact Email*

Credentialing Contact Phone*

CAQH ID Number*

To ensure we have access to download your CAQH application, please include Mount Carmel Health Partners to your list of Authorized Plans. The application needs to be complete and current (attested to within 30 days of submission) and re-attested to every 120 days thereafter. All 26 Disclosure Questions must be answered.

CAQH Disclosure
If applicant answered affirmatively to any CAQH disclosure question he/she must complete the Disclosure Question Narrative form. Completion of this form is required in addition to the CAQH disclosure questions supplemental form.
Open the form here.

Upload completed Disclosure Question Narrative form

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Current Curriculum Vitae/ Resume

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A current curriculum vitae/resume may be submitted to produce the most recent 5 years of work history (month/year format). This must match the CAQH. Gaps 6 months or greater must be explained in writing.

Current Professional Liability Insurance Face Sheet*

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Coverage minimums of $1M/$3M, with expiration date and applicant’s name.

DEA – Drug Enforcement Administration (If Applicable)

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Copy of current, valid DEA registration certificate with Ohio address and expiration date.

Corporate W-9 with Tax ID Number*

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To be consistent with what is reported on the CAQH application and with Group Participating Provider Agreement (PPA).

CLIA Certificates (If Applicable)

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Provide copies of all current certificates in which laboratory services are provided.

CNP, CNS, CNM Applicant Standard Care Arrangement

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PA Applicant Supervision Agreement

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CRNA Applicant Name of Supervising Physician

Physician Applicant Cross Coverage Designee Name *

All Physicians with or without a hospital affiliation must provide an in CIN (Clinically Integrated Network) cross coverage designee and in CIN hospital admitting arrangements. Coverage by hospitalist group is acceptable coverage.

Description of Services

What services will the applicant provide as it pertains to the Mount Carmel Health Partners CIN? (Examples: function as a hospitalist, work in an urgent care, provide pain management services, etc.)

Hospital Affiliation

If the applicant has clinical privileges at any Franklin County acute care hospital, (excluding LTAC) he/she must hold current and unrestricted allied health or medical staff privileges at one or more Mount Carmel Health System hospitals unless one of the following exceptions applies:

(1) the participating provider does not provide inpatient services at an acute care hospital; or

(2) the participating provider's primary medical practice location is outside of Franklin County, that is, more than 75% of the participating provider's patient contact hours occur at a location(s) outside of Franklin County; or

(3) the participating practitioner’s specialty is pediatrics and he/she is employed by, or contracted through, Partners for Kids.

The applicant holds clinical privileges at the following Franklin County acute care hospitals (excluding LTAC):

If applicable indicate which exception applies:

National Practitioner Data Bank

If the applicant has any knowledge that information pertaining to him/her has been reported to the National Practitioner Data Bank, an explanation regarding the report must be provided on the Disclosure Question Narrative form.
See CAQH Disclosure section above.

National Practitioner Data Bank

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If you have knowledge that information pertaining to you has been reported to the National Practitioner Data Bank, an explanation regarding the report must be provided on the CAQH or submit a written statement.

Application Fee

There is no fee for Recredentialing.

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