Re-Credentialing Application – Tennessee

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Re-Credentialing Application
	Re-Credentialing Checklist A provider checklist to ensure everything is included when the application is returned.
	Tennessee Credentialing Application for Healthcare Practitioners
	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 Form 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