Provider Credentialing Form

The 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;
  • 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
*Providers that are NOT enrolled in the FMBS account management tier, will be required to pay a fee of $175.00 per contract application per provider/facility entity using the provided link

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 or by fax it to 1.623.374.4592 (the 1 is required in front).

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