Required Documents for Providers
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Last Revised 12.30.2019 TLK
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https://nationalcredentialing.com Required Documents for Providers
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Provider Type:LicenseCVDEA/CSRMalpractice InsnCred ReleaseDiploma from
Highest Level of Education
ECFMG
Board Certification
Drivers LicenseSupervising Physican ProtocolCollaborating Agreement/
Nurse Protocol Agreement
State Release AKA CAQH Authorization Release
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DOCUMENT COPY STORAGE: (if Provider Type is marked YES)SF & CAQHSF Only (unless a specific state requires the doucment)SF & CAQHSF & CAQHSF OnlySF & CAQHSF & CAQHSF & CAQHSF OnlySF & CAQH SF & CAQHCAQH (doc will be found in SF on Profile or Validation Case)
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MD / DOYes YesYes YesYesNoYes, if applicableYes, if applicable YesNoNoYes
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Physican AssistantYes YesYes YesYesYesN/AYesYesYesNoYes
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NPYes YesYes YesYesYesN/AYesYesNo
Yes (if applicable*)
Yes
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Behavioral Health (LCSW,LPC,etc)
Yes YesNoYesYesYesN/AN/AYesNoNoYes
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OT/PT/SLPYes YesYes, if applicableYesYesNoN/AYes, if applicable YesNoNoYes
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ODYes YesYes, if applicableYesYesYesN/AYes, if applicable YesNoNoYes
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AudiologistYes YesNoYesYesYesN/AYes, if applicable YesNoNoYes
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PsyDYes YesYes, if applicableYesYesYesN/AYes, if applicable YesNoNoYes
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DPMYes YesYes, if applicableYesYesNoN/AYes, if applicable YesNoNoYes
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Doctor of ChiropracticYes YesYes, if applicableYesYesNoN/ANoYesNoNoYes
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*If an MD, DO, PA, or NP does not have Hospital Privileges, obtain an Admitting Arrangement
*varies by state
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*If an MD, DO, PA, or NP does not have a DEA, obtain a Prescribing Agreement
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Required Documents for Business Entities
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Organization TypeCP-575 or 147CW-9CLIA CertificateBank Letter* or voided check
Rental Agrmnt
Fictitious Name
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Corp, LLC, PC, etcYesYesYes, if applicableYes, for Medicare enrollmentNoYes, if in CA (and entity must be a Corp)
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Any entity for PT/OT that is not part of an MD practice
YesYesYes, if applicableYes, for Medicare enrollmentYesYes, if in CA
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Sole ProprietorNoYesYes, if applicableYes, for Medicare enrollmentNoNo
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*Bank letter is verification from your bank of the business bank account held by your practice.
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The letter must be on bank letterhead and must include: The full legal business name in which the account is held (must exactly match the name shown on CP-575), the type of account (checking, savings), the routing number, the account number, the bank mailing address and phone, and signature of a bank official who can be contacted to verify the information.
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Required Documents & Information for Medicare DMEPOS Applications (in addition to all requirements above)
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Product Liability InsuranceBusiness HoursInsurance Agent and underwriter informationSpecify DME products soldSurety BondDMEPOS Accreditation Certificate
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Physician PracticeYesYesYesYesNoNo
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ChiropractorYesYesYesYesYesYes
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DC & MD ownedYesYesYesYesNoNo
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Notes:
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Product liability insurance is separate from malpractice insurance. NSC must be listed a certificate holder on the COI
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