Core Documents and Information for an individuals:

Physicians:

1. Practitioner License(s)*
2. Malpractice Insurance (Certificate of Insurance)*
3. DEA (federal) and state CSR certificates (if applicable)*
4. Board Certification(s) (if applicable)*
5. ECFMG Certificate (required if educated outside of The United States)*
6. Fellowship Certificate of Completion (if applicable)*
7. Current copy of CV (showing current employer)*
8. Current driver’s license*
9. Covering physicians list (if solo practice)*
10. NPI
11. CAQH ID, username and password
12. CMS I&A surrogate access (requires you to authorize nCred with surrogate access for filing Medicare applications)

Mid-Level Providers (NP, PA, etc), Therapists (PT, OT, SLP, etc), and other healthcare providers:

1. Practitioner License(s)*
2. Malpractice Insurance (Certificate of Insurance)*
3. DEA (federal) and state CSR certificates (if applicable)*
4. Board Certification(s) *
5. Diploma – copy of highest level of education (Master’s degree, PA, DPT, etc)*
6. Current copy of CV (showing current employer)*
7. Collaborative Agreement * (required for NP’s practicing in states with less than “Full Practice” practice environments)
8. Supervising Physician Agreement * (required for PA’s)
9. Current driver’s license*
10. NPI
11. CAQH ID, username and password
12. CMS I&A surrogate access (requires you to authorize nCred with surrogate access for filing Medicare applications)

Behavioral Health Practitioners

1. State License*
2. Current copy of CV (showing current employer)*
3. Malpractice Insurance (Certificate of Insurance)*
4. Diploma – copy of highest level of education*
5. Special Certification(s) (if applicable)
6. Current driver’s license*
7. NPI
8. CAQH ID, username and password
9. CMS I&A surrogate access (requires you to authorize nCred with surrogate access for filing Medicare applications for practitioners eligible to enroll with Medicare)

Other documents that may be applicable:

1. Passport or other citizenship documents (if born outside U.S. and not previously enrolled in Medicare)
2. Admitting Arrangement letter – may be required from commercial insurance networks for providers who do not have hospital admitting privileges in order to contract with commercial insurance networks
3. Prescribing Arrangement Letter = may be required from some commercial insurance networks for providers who will not have prescribing authority with DEA and/or CSR in order to contract with commercial insurance carriers.

Documents and Information needed for your legal entity:

1. Physical service location where patient services are rendered* (not a residence, “Virtual Office”, or PO Box)
2. IRS Form W-9*
3. IRS form CP575 or replacement letter 147C (verification of EIN)*
4. Bank account verification* – either pre-printed check with the business name exactly as shown on the IRS form CP575 or a letter from your bank verifying your bank account. The voided check or bank letter must have the business name precisely as on file with the IRS including punctuation, abbreviations, etc. No deviation from the name is allowed by Medicare including corporate suffix such as Inc or LLC, etc. If using a bank letter, it must also include the type of account (checking or savings), the account routing number, the account number, and be signed by a bank representative and written on bank letterhead.

Other documents that may be applicable for your business entity:

1. CLIA Certificate (if applicable)
2. Business License (if applicable to your area)
3. Fictitious Name Permit (if applicable in your area) – required in CA
4. State and local license as may be required by your state (FL requires a healthcare clinic license or certificate of exemption)
5. Copy of office lease (required for independent therapy facilities to enroll with Medicare)

*Required