Forms
Credentialing Applications
To credential a new practitioner or organizational provider, complete the appropriate application below and return with all required documents specified in the Credentialing Matrix.
Each provider and organization NPI is required to be credentialed. The credentialing process may take up to ninety (90) business days for completion. Notification will be provided once a credentialing decision has been made.
If you do not have an active Agreement,
Contact PacificSource.
Adds, Changes and Terms
To add a currently credentialed or hospital based provider to an existing group, to update provider demographic information for existing providers or to remove a provider from your group, please complete the Provider Information Request.
Supplemental Forms
Hospital Admit Plan: required in the event a practitioner (MD, DO, NP, CNM, CNS or PA) does not hold active admitting privileges at a participating hospital.
Prescribe Plan: required in the event a practitioner (MD, DO, DPM, NP, CRNA, CNM, CNS or PA) does not hold a DEA certificate in the state for which they provide services.