Re-Credentialing Application – North Carolina

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Re-Credentialing Application
	Re-Credentialing Checklist A provider checklist to ensure everything is included when the application is returned.
	North Carolina Department of Insurance Uniform Application to Participate as a Health Care Practitioner Standardized application for Healthcare Entities that contain identical questions that are needed for the credentialing process.
	Provider Information Form
	Location Information Update Form
	Patient Feedback Survey
	Provider Satisfaction Survey
	Release Authorization Signature and date verifying that all information is true and complete.
	Business Associate Agreement Terms of business relationship with ActivHealthCare. Must agree, sign and date.
	Provider Agreement Terms of provider membership with ActivHealthCare. Must agree, sign and date.
	Certificate Holder Request Request from your insurance company to list Integrated-ActivHealthCare as a certificate holder and verification of your professional liability insurance coverage as well as your medical malpractice claims history.
	CMS Worksheet Form for determining business interests.
	W-9 Tax Form