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

Complete Outpatient Laboratory Provider Application

Complete Outpatient Laboratory Provider Application

If you are interested in providing the CHW Benefit to Alliance members in Merced, Monterey and/or Santa Cruz counties, you will need to apply to be credentialed.

To be credentialed and start work as an Alliance provider, you will need to complete the following steps.

Be screened and enrolled as a Department of Health Care Services (DHCS) Medi-Cal provider.

All CHW Care Based Organizations are required to enroll with DHCS. Providers must enroll in Medi-Cal if a state-level enrollment pathway exists. To do so, use the standardized application form for the DHCS Medi-Cal program. You will need to create a User Profile on the website to do so.

If a CHW Care Based Organization is a non-traditional provider type for whom there is no established credentialing pathway, the Alliance will verify the provider’s credentials through Alliance credentialing in addition to requiring any or all the following documents:

• Applicable business or professional license.
• IRS Form 990.
• Nonprofit status.
• Other documentation demonstrating official established business and/or individual entity.

Submit an Alliance credentialing application and all the required supplemental forms to become an Alliance provider.

Have a contract with the Alliance that includes these services.

New Provider Training

Once you have completed these steps, you will also need to complete the Alliance’s New Provider Training. 

Ready to start applying? Please follow the directions in the Community Health Worker Organization Provider Credentialing Application.

If you have any questions, please contact [email protected].

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

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Member Eligibility
Claims Submission (Coding, Modifiers)
CHC Set up

Complete Doula Provider Credentialing Application