EFFECTIVE FEBRUARY 1, 2013 THE ALLIANCE PROVIDER NETWORK IS CLOSED. Get more information.
Please note that MAY 15 IS THE FINAL DATE for providers who received a request for additional information to return all documentation necessary to complete credentialing. Providers, refer to the May 10 Weekly Update for additional important credentialing information!
DOCUMENTS BEING REQUESTED IN APPLICATION SCREENING
Culture, Gender and Linguistics Data Form
Supplemental Information on Managing Employees, Owners, Directors and EFT Authorized Employees
Automobile Waiver Attestation Form
Background Release Form
Site Enrollment Form
FOR LICENSED PRACTITIONERS AND PROVISIONALLY LICENSED/ASSOCIATES
(The Network is closed for Licensed Independent Practitioners)
Step-by-Step Credentialing Instructions
Enrollment Application and Related Documents