Provider Credentialing Applications and Policies

Complete Physician Provider Credentialing Application

If you are a(n):

• Allopathic Physician (MD).
• Osteopathic Physician (DO).
• Podiatrist (DPM).

Complete Non-Physician Medical Practitioner Credentialing Application

If you are a:

• Physician Assistant (PA).
• Nurse Practitioner (NP).
• Licensed Midwife (LM).
• Certified Nurse Midwife (CNM).
• Certified Registered Nurse Anesthetist (CRNA).

Complete Allied Provider Credentialing Application

If you are a(n):

• Physical Therapist.
• Occupational Therapist.
• Speech Therapist.
• Audiologist.
• Hearing Aid Dispenser.
• Optometrist.
• Acupuncturist.
• Chiropractor.

Complete Organizational Provider Application

This application should be completed by the following:

• Ambulatory Surgical Center (freestanding only).
• Home Health Agency.
• Hospital (all types).
• Skilled Nursing Facility/Long Term Care.
• Hospice.
• Sleep Center/Sleep Lab (freestanding only).
• CBAS (ADHC).
• Freestanding Birth Centers (licensed only).

Complete Durable Medical Equipment Provider Application

Become a Doula at the Alliance Checklist

• Department of Health Care Services Medi-Cal Enrollment - Provider Application and Validation Enrollment (PAVE)
  • NPI (National Provider Identifier) (How to obtain an NPI)
  • HIPAA Training Attestation
  • CPR Certification
  • Business License
  • Insurance
• Contract & Credential with the Alliance
  • Credentialing Application
  • Provider Information Request
  • W9
  • Sign Contract
• Training
  • Member Eligibility
  • Claims Submission (Coding, Modifiers)
  • CHC Set up

Complete Doula Provider Credentialing Application