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CAQH AUTOMATICALLY APPLIES MIXED-CASE FORMATTING, COMMON ABBREVIATIONS, AND ZIP CODE MATCHING. PLEASE MAKE CORRECTIONS ONLINE OR CALL THE HELP DESK. YES NO CITYOF BIRTH STATE OF COUNTRY OF BIRTH Code list is found on page 36. Enter the associated 3-digit code in the space provided.* NOTE: CAQH will use this method for application follow-up.
Instructions. Read all instructions carefully prior to submitting your application. INCORRECT MARKS: •. Tips to avoid processing delays: Complete only this application and its supplemental forms. Do not use another provider’s application. Use a blue or black ink ball-point pen only. Do not use a pencil or a felt-tip pen.
The CAQH application is an online service where practitioners can provide standardized credentialing information to multiple organizations without filling out multiple forms. By signing the CAQH Standard Authorization, Attestation and Release form you
Explore CAQH Solutions for provider credentialing and verification, directory maintenance, coordination of benefits and more. CAQH is a non-profit alliance of health plans and related associations working together to streamline the business of healthcare.
PROVIDER APPLICATION REQUEST FORM (For CAQH participants only) CAQH Number: Medical License/Certification Number: NPI Number: Date of Birth: Provider Last and First Name: Requested Contract Entity: Blue Shield of California Health Plan ... Please email the completed form to BSCInitialApp@blueshieldca.com. Author:
Read all instructions carerully prior to submitting your application. Tips to avoid processing delays. Complete only this application and its supplemental forms. Do not use another provider's application. Use a blue or black ink ball-point pen only. Do not use a pencil or a felt-tip pen.
Physicians and other healthcare professionals obtain their CAQH provider ID directly from CAQH by going to and completing a registration form. Once the form is submitted, the applicant will receive an email from CAQH with a CAQH provider ID.
If you need a paper copy of the application please call the CAQH help desk at (888) 599-1771 to obtain a paper application. Upon completion of the paper application, please fax the application and supporting documentation to CAQH.
Summary Pages are not accepted. Click on Review and Attest (4th row right ) Scroll down. You will see 3 options-. Choose Download your State Application.
The above button links to a printable version (.pdf) of the District of Columbia'’s credentialing application that you can complete by hand and mail to health plans. The downloadable file contains the 18-page application and supplemental forms and reference codes.