Get Alohacare Credentialing Email Form - Alohacare

Filling out the Alohacare Credentialing Email Form requires careful attention to detail and accuracy. This guide provides step-by-step instructions to ensure that users can complete the form effectively and efficiently.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the form and open it in your editing tool.
2. Enter your identification and demographics. Complete fields such as last name, first name, and social security number. Include your date of birth and provider classification, selecting the appropriate choices that apply to you.
3. Fill out the professional IDs section. Input your National Provider Identification Number, Medicare number, and Medicaid number, if applicable. Indicate whether you have submitted an affidavit with Medicare to opt out of the program.
4. Complete the office information section by providing details about your primary location, including practice name, date joined, federal tax ID number, address, and contact information.
5. Enter your state licensure details. List all current or held licenses over the last five years, including issuing state board, license number, and expiration dates.
6. Fill out the board certification and specialties section, indicating if you are board certified and providing details of any additional certifications.
7. Provide your education history by including the education level, school name, graduation date, and degree awarded.
8. Complete the training section, including internship, residency, or fellowship details if applicable.
9. If required, provide information about your professional liability insurance, including policy number, carrier name, and coverage amounts.
10. Fill in your hospital affiliations, detailing your primary and any additional hospital affiliations, including contact details and admitting privileges.
11. Summarize your professional practice history over the required time period, ensuring to include organization names and dates of employment.
12. Answer the questionnaire section truthfully, and provide explanations on a separate sheet if you answer 'yes' to any questions.
13. Complete the attestation and consent form, ensuring to provide your signature and date to validate your application.
14. Finally, review all entered information for accuracy, save any changes, and prepare to download, print, or share the completed form as needed.

Take the next step in your credentialing process by completing the Alohacare Credentialing Email Form online today.