 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
These pdf forms are provided for your convenience. If you have any questions, call us at (828) 670-9145.
EMPLOYEES
Employee Request for Physician Participation in Crescent Preferred Provider Network
PHYSICIAN PROVIDER APPLICATION FORMS
Credentialing
Application (Word document)
Credentialing
Application (PDF)
Participating
Physician Agreement
Physician
Fee Submission Form
Physician
Provider Checklist
IRS
W-9 Form
Contract amendment
for Fully Insured products
ALLIED PROFESSIONALS APPLICATION FORMS
Credentialing
Application
Allied
Health Provider Agreement
Exhibit
D - Antitrust Policy
Exhibit
D - Guidelines
Physician
Fee Submission Form
Allied
Provider Checklist
IRS
W-9 Form
Contract amendment
for Fully Insured products
FACILITY/HOSPITAL APPLICATION FORMS
Participating
Facility Agreement
Insurer Amendment - Participating Facility Agreement
Participating
Hospital Agreement
Insurer Amendment - Participating Hospital Agreement
|
|
Crescent
Health Solutions 1200 Ridgefield Blvd., Suite 215 Asheville, NC 28806 Phone:
828-670-9145
|
|||
