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Sample Credentialing Checklist

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  • Sample Credentialing Checklist

We utilize industry standard credentialing forms to advance/expedite the provider enrollment process when a new provider joins the FQHC.

Information Needed

  • Hire date
  • Legal name as it appears on the Social Security card
  • Date of Birth
  • City, State, country of birth
  • NPI number
  • Social Security number
  • License numbers, including issue and expiration dates
  • DEA number, including issue and expiration dates (if applicable)
  • Name of College where they received their degree
  • Date of graduation, including month and year
  • U.S. Citizenship answered "Yes" or "No"
  • CAQH number, sign-on and password

Documents Needed

  • Current CV with dates in MO/YYYY format (CV should be complete, including addresses of schools and employment)
  • Medical License
  • DEA License
  • Certification (for NP/PA)
  • Board Certification
  • ECFMG documentation if applicable
  • Individual liability face sheet (if applicable)
  • Detailed explanation of any malpractice suits
  • Detailed explanation of any ‘yes' answers on the credentialing application
  • Diploma/Master’s Degree
  • Proof of ability to work in the USA (if not a citizen)
  • Copy of Social Security Card is helpful
  • Copy of Driver's License (often requested)