Credentialing Status Page: Credentialing StatusProvider InformationDate of Request:Last Name or Facility:First Name:Title:Group Name:Mailing Address:City:State:Zip Code:Contact InformationName:Tax ID:EmailPhone:Fax:Requested Items / ServicesCheckbox Field Client ListCheckbox Field Provider / Facility ManualCheckbox Field Request your Contracted Rates / Fee Schedule / Enter CPT Codes below:TextareaCheckbox Field Status of Credentialing ApplicationCheckbox Field Request a Service VisitCheckbox Field Other, please explain:TextareaSubmit Request
