Initial Provider Credentialing Request - Personal Information

*Note: The following form should only be completed for professional providers looking to enroll in the Delaware Market and Networks.
Professional providers looking to enroll in the following Markets: Pennsylvania, New York or West Virginia should complete the Initial Credentialing Request Form located on our provider resource center and enroll through the CertifyOS Initial Credentialing Intake Portal.
Instructions: Complete the section below and the address section on the following screen. Once you begin your request, you must complete it in one session as you will not be able to save it and complete at a later time. Once you submit an Initial Provider Credentialing Request, you will not be able to change and re-submit. Fill in all applicable fields and review your data for accuracy. After completing this section, click Next to enter address information.
Name
Last Name
First Name
Middle
Suffix
National Provider ID (individual, not group)
Date of Birth mm/dd/yyyy
CAQH ID
Highmark ID (individual, not group)
Practitioner Type Degree

Please only provide the specialties and roles for which you are requesting Credentialing. This information will be used in our Network Directory.
Primary Specialty Primary Specialty Role
Secondary Specialty Secondary Specialty Role
Credentialing Contact Email Address
Credentialing Contact Name