Skilled Policy Intake form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.STATEAgency Name *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone * Certificate Clinical Email FaxHoursCounties ServedOwner Name *Administrator *Alternate AdministratorClinical Manager *Alternate Clinical ManagerGoverning Body *At Least 2 members requiredGroup/Practice Information Group NameDBA, if anyServicing AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBilling/Pay-to AddresAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeGroup NPIEmail *PhoneFaxList of Required Documents Please attach copies of the following documents, which are required to initiate and process the credentialing application (s). Criminal Background Check Click or drag a file to this area to upload. IRS Letter Click or drag a file to this area to upload. Business License Click or drag a file to this area to upload. CLIA (If Applicable) Click or drag a file to this area to upload. Certificate of Incorporation Click or drag a file to this area to upload. Board Certificate: Click or drag a file to this area to upload. Malpractice Certificate Click or drag a file to this area to upload. Collaborative Agreement Click or drag a file to this area to upload. Ownership Information (SSN) Click or drag a file to this area to upload. Organizational Chart Click or drag a file to this area to upload. Program DescriptionSubmit
