Central Verification Office Application Request

Please fill out the following information to receive your credentialing application and materials. If you do not have a CAQH ID, please email the Premier Health Central Verification Office directly or you can request a CAQH ID.

Name

CAQH ID

All materials and communications will be sent to this email address.

Mobile Phone

Provider Group Name

Credentialing Contact (optional)

Please select your role

Please select your title

Specialty

Are you currently credentialed at a Premier Health hospital?

Primary Hospital

Anticipated start date

Were you credentialed within the last six months?

Select Secondary Hospital(s) if desired (optional)

Note: If your credential date is more than 6 months in the past, you will be charged an additional fee for adding a secondary hospital.

Initial Credentialing at an additional Premier Health hospital (optional)

Note: If your credential date is more than 6 months in the past, you will be charged an additional fee for adding a secondary hospital.

Recredentialing/Annual Fees at a Premier Health hospital (optional)

Comments (optional)