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Credentialing and Recredentialing

We require this form for credentialing and recredentialing. By signing it, you attest to the accuracy of the information in your credentialing application and consent to the release of information we need to evaluate your request. The form must be dated within 180 days of your request.

Submit this form when credentialing or recedentialing to attest that you maintain the required minimum professional liability (malpractice) insurance of $1M/$3M coverage.