Provider Credentialing Services
Sign in to Google to save your progress. Learn more
Full Name *
Date of Birth *
Place of Birth *
Individual NPI *
Group NPI
Degree *
Start Date of Practice *
License Number *
Are you specialty board certified? *
If yes, which specialty? *
Do you have hospital privileges? *
If yes, what is the status of your privileges?
Clear selection
Where are you hospital privileges?
Practice Name *
Primary Address *
Phone Number *
Fax Number *
E-mail Address
Office Hours *
Do you have a Council for Affordable Quality Healthcare (CAQH) ID number? *
If yes, what is your CAQH ID number?
Please e-mail the following documents to: with the subject line "Credentialing - Your Name" current license, DEA certificate, board specialty certificate (if applicable), malpractive insurance certificate, and CV for the last 5 years (including the month and years).
At Healthcare Partners Consulting and Billing we offer a wide range of services, beyond provider credentialing, to include comprehensive billing services, virtual office management, as well as consulting and accounting services. Would you like to receive information about any of these services? *
Do you have any questions or comments?
Clear form
Never submit passwords through Google Forms.
This form was created inside of Health Partners Consulting and Billing, LLC. Report Abuse