Credentialing Primary Source Verification Directory (August 2017)

How should fellow credentialing offices submit verification requests to you?

Credentialing Resource Center is compiling and updating our directory of medical staff/credentialing contacts. The Credentialing Primary Source Verification Directory provides the direct contact information and primary source verification request procedures for more than 5,300 organizations.

We would like to confirm the appropriate contact within your office that should receive requests for credentials verification from other facilities.

Thank you in advance for helping us to update our information.

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* 1. Please fill in the contact information below for incoming credentials verification requests (usually the credentialing office).

Name and title of contact person for verifications:

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* 2. Name of the department that handles verification requests:

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* 3. Organization name:

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* 4. Street/Mailing address:

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* 5. City:

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* 6. State:

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* 7. Zip:

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* 8. Email address for verification requests:

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* 9. Please fill in the current telephone and fax numbers for credentials verification requests.

Telephone:

Fax:

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* 10. Please include your medical staff office's website address. (If your department doesn't have its own web page, please include the most informative link for obtaining information from your office):

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* 11. Do you charge for answering credentials verification requests?

Yes

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* 12. If you charge for credentials verification requests, what is the fee?

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* 13. Do you require physician/provider signed releases in order to release information?

Yes

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* 14. Which of the following methods is accepted or not accepted for sending credentials verfication requests to your office?

	Acceptable	Not acceptable
Telephone	Telephone Acceptable	Telephone Not acceptable
Mail	Mail Acceptable	Mail Not acceptable
Email	Email Acceptable	Email Not acceptable
Via website	Via website Acceptable	Via website Not acceptable
Fax	Fax Acceptable	Fax Not acceptable

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* 15. If you accept verification requests via your website, please indicate the URL for requests, if different from above:

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* 16. What types of verifications does your office provide? (Please check all that apply).

Annual report, listing, directory, or roster of licensed physicians

Verification of certificates

Verification of degrees

Verification of degrees, MD only

Verification of licenses, MD

Verification of licenses, DO

Verification of internships

Verification of residencies

Verification of work history

Verification of membership or affiliation

Verification of licenses, advanced practice professionals

Other, please specify

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* 17. Please describe any special rules or policies that you have regarding verification requests.

Thank you for submitting or confirming your listing information!

Question Title

* 1. Please fill in the contact information below for incoming credentials verification requests (usually the credentialing office).Name and title of contact person for verifications:

Question Title

* 2. Name of the department that handles verification requests:

Question Title

* 3. Organization name:

Question Title

* 4. Street/Mailing address:

Question Title

* 5. City:

Question Title

* 6. State:

Question Title

* 7. Zip:

Question Title

* 8. Email address for verification requests:

Question Title

* 9. Please fill in the current telephone and fax numbers for credentials verification requests.

Question Title

* 10. Please include your medical staff office's website address. (If your department doesn't have its own web page, please include the most informative link for obtaining information from your office):

Question Title

* 11. Do you charge for answering credentials verification requests?

Question Title

* 12. If you charge for credentials verification requests, what is the fee?

Question Title

* 13. Do you require physician/provider signed releases in order to release information?

Question Title

* 14. Which of the following methods is accepted or not accepted for sending credentials verfication requests to your office?

Question Title

* 15. If you accept verification requests via your website, please indicate the URL for requests, if different from above:

Question Title

* 16. What types of verifications does your office provide? (Please check all that apply).

Question Title

* 17. Please describe any special rules or policies that you have regarding verification requests.

* 1. Please fill in the contact information below for incoming credentials verification requests (usually the credentialing office).

Name and title of contact person for verifications: