Group Practice Package

Memo

To:

New CredAxis Provider Group

From:

Elizabeth Duffin (Collins), Credentialing & Project Manager, eduffin@credaxis.com Matt Romeo, Project Manager, mromeo@credaxis.com,Sherry zamot cred.cordinator szamot@credaxis.com

Re:

New Provider Group Information

Dear Provider,

Welcome to the CredAxis Family!

Please complete the paperwork attached to get your credentialing process started . Please be sure to sign all paperwork in BLUE INK (DO NOT DATE ANY DOCUMENTS) at area denoted by a *. This is indicative of the required originals when we forward paperwork for processing . Please do not skip any portions of the attached provider group information forms.

Kindly return copies of your group New Practice Checklist Documents (We do not need the originals) with your signed paperwork. Any missing or incomplete information will delay the credentialing process.

Please contact us if you have any questions.

Regards,

Elizabeth Duffin (Collins)
Credentialing Manager

Matt Romeo
Project Manager

Logo

Attention: Credentialing Department
1214 Mariner Blvd
Spring Hill, FL 34609-5657

New Practice Check List

  1. In order to register your organization & contract we must have a copy of your IRS CP575.
  2. What is a CP575?
    • This is an IRS generated letter you receive when applying for a Tax Identification Number (AKA Employer Identification Number) and linking it with your newly developed companies Legal Business Name (LBN) IRS CP575


  1. Bank Letter : Please contact your bank and request they draft a letter with the following information included:
    • Your Group Name ( As listed on CP575)
    • Account Type (Business Checking or Business Savings)
    • Account Number
    • Routing
    • Name of Bank, Full Contact Name, Phone# and address.
    • Signature of bank representative



  2. Voided Check : Please provide 5 voided checks for set up of EFT Agreements
  • We will assist in applying for this number if the group doesn’t have one.
  • Practice Location
  • Billing Address
  • Payment Address Information
( Instruction : Please download the form W-9 and Please Sign Only)
Download

Group Demographic Information Form

Corp Type

Incorporation Date

Group NPI Registration

Practice Location Information

Primary Secondary Tertiary Practice Location :

Office Contact

Email Address

Location Effective Date

Address

City

State

Zip-Code

Phone

Fax

Back Office Number

Accessibility

Does this office provide handicapped accessibility?

Building Access?

Restroom Access?

Wheelchair Access?

Text TTL?

Mental / Physical Impairment Services?

What Days of the week & hours will you be at this location?

Day Start Time End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Treating Age Ranges

Services: Please Select all appropriate services for this location

What Providers will be listed at this location?

Correspondence Address

Address

City

State

Zip-Code

Phone

Fax

Contact Name

Email

Payment Address

Address

City

State

Zip-Code

Phone

Fax

Contact Name

Email

Billing Address

Address

City

State

Zip-Code

Phone

Fax

Contact Name

Email

Insurance Information Form

Please select the plans your practice is currently participating with & the panel status

Payer Name LINES OF BUSINESS
Ex:C-Commercial,MCR-Medicare,MCD-Medicaid
Group Provider ID Panel Open or Closed Attach File
MEDICARE
MEDICAID
BCBS
Tricare Standard
Tricare Prime
Humana

Please provide copies of all contracts currently in effect & all insurance contacts.

Insurance Authorization

Please download the Insurance Authorization form by clicking download button below and complete the PDF file attached and upload it by clicking upload button below to get your credentialing process started. Please be sure to digital sign PDF file attached.

Download