Provider Credentialing FormThe Credentialing form will be used for 1 of 2 services.
Service One: In order to have an account created with FMBS for billing services the information on this page is required.
Service Two: Preparation to become a contracted provider. In the event you have decided to become a contracted provider with insurance, there are a few required items.
- 1. NPI for the provider rather it is a person or facility
- 2. TIN that will be used
- 3. Malpractice Insurance that covers the provider OR the facility OR both entities (1M/3M aggregate)
- 4. CAQH Number and Account for the provider; https://proview.caqh.org/PR/Registration
- 5. A list of insurance that you are interested in contracting with for FMBS to confirm new insurance contracts are being accepted
- 6. The FMBS Credentialing Form listed below
This service includes application submission and follow up until the application has provided a contract OR has denied by the payer.
The credentialing process from start to finish takes about 120 business days and will followed up on a monthly basis.
For multiple providers please print, complete, and return Provider Registration Form by email to firstname.lastname@example.org or by fax it to 1.623.374.4592 (the 1 is required in front).