North Carolina



Online Credentialing Application Now Available


You now have the option of submitting your credentialing application online or using the paper documents below. To complete the online application, click here

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Adobe Acrobat or Adobe Acrobat Reader is required to open the .PDF files listed below.

Initial Credentialing Application
Initial Checklist
A provider checklist to ensure everything is included when the application is returned.
Requirements for Participation
Applicants must meet all standards that are listed to be considered for participation.
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.
W-9 Form
W-9 Tax form to be completed and submitted initially and whenever there is a tax related change.