Resource Center
Forms Directory
Find, preview, and download enrollment and credentialing forms for every major insurance payer.
| Form Name | Payer | Online | Required | Download |
|---|---|---|---|---|
|
Carelon Behavioral Health Provider Application
Provider application for Carelon Behavioral Health (formerly Beacon Health Optio...
|
Carelon Behavioral Health | Online | Required | Download |
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Centene Provider Interest Form
|
Centene Corporation | Online | Required | N/A |
|
CHAMPVA Claim Form (VA Form 10-7959a)
Standard claim submission form for CHAMPVA-covered services rendered to eligible...
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CHAMPVA | Offline | Optional | Download |
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CHAMPVA Provider Agreement (VA Form 10-583)
VA form required for providers to participate in the CHAMPVA network as an autho...
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CHAMPVA | Offline | Required | Download |
|
Cigna Dental Provider Application
Provider application to join the Cigna Dental PPO or DHMO network.
|
Cigna Dental | Online | Required | Download |
|
Cigna e-Onboarding Application
|
Cigna Healthcare | Online | Required | Download |
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CMS-855B — Group Practices / Organizations
For group practices, clinics, and organizations billing Medicare for services re...
|
Medicare Fee-for-Service (CMS) | Online | Required | Download |
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CMS-855I — Individual Practitioners
For physicians and non-physician practitioners enrolling as individuals who will...
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Medicare Fee-for-Service (CMS) | Online | Required | Download |
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CMS-855O — Ordering/Certifying Only
For physicians who ONLY order or certify items/services for Medicare beneficiari...
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Medicare Fee-for-Service (CMS) | Online | Optional | Download |
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CMS-855R — Reassignment of Benefits
Used when an individual practitioner reassigns their billing rights to a group p...
|
Medicare Fee-for-Service (CMS) | Online | Optional | Download |
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CMS-855S — DMEPOS Suppliers
For suppliers of durable medical equipment, prosthetics, orthotics, and supplies...
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Medicare Fee-for-Service (CMS) | Online | Required | Download |
|
Colorado Medicaid Provider Enrollment
|
Health First Colorado | Online | Required | Download |
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CT Medicaid Provider Enrollment (CTMAPS)
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Connecticut HUSKY Health | Online | Required | Download |
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Davis Vision Provider Network Application
Provider application to join the Davis Vision provider network.
|
Davis Vision | Offline | Required | Download |
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DC Medicaid Provider Enrollment
|
DC Medicaid | Online | Required | Download |
|
DD Form 2672 — Physician Certification
Department of Defense physician certification form required for initial TRICARE...
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TRICARE | Offline | Required | Download |
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Delaware Medicaid Provider Enrollment
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Delaware Medicaid | Online | Required | Download |
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Delta Dental Provider Application
Provider application to join the Delta Dental Premier or PPO network.
|
Delta Dental | Online | Required | Download |
|
DentaQuest Provider Enrollment Form
Provider enrollment form for DentaQuest Medicaid and managed dental programs.
|
DentaQuest | Online | Required | Download |
|
Evernorth Behavioral Health Provider Application
Provider application for the Evernorth (Cigna) behavioral health network.
|
Evernorth Behavioral Health | Online | Required | Download |