Initial Credentialing Application - North Carolina

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Initial Application
	Initial 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 Form
	Release Authorization Signature and date verifying that all information is true and complete.
	Business Associate Agreement Terms of business relationship with Integrated-ActivHealthCare. Must agree, sign and date.
	Provider Agreement Terms of provider membership with Integrated-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 Form W-9 Tax form to be completed and submitted initially and whenever there is a tax related change.