CareSkyUSA Provider Credentialing Checklist

Complete all sections to initiate your credentialing process

Owner Information

Full Name

Cell Number

Email Address

Home Address

Service Address

Mailing Address

How Many Providers?

Select type of Provider

Select number of providers

Practice Information

Practice / Facility Name

Tax ID (EIN)

Practice Address

Practice Phone

Practice Fax

Practice Email

Mailing Address

Service Location

Licensure & Certification

Provider License

State License Number

License Expiration Date

DEA Number

DEA Expiration Date

Board Certifications

Facility License

State License Number

License Expiration Date

DEA Number

DEA Expiration Date

Board Certifications

Provider Resume / CV

📄

Click to upload or drag and drop

PDF, DOC, DOCX (Max 10MB)

PECOS & CAQH Credentials

PECOS ID / Credential Number

CAQH ID / Credential Number

Required Documents

📋

State License

PDF, DOC, DOCX

🛡️

Malpractice Insurance

PDF, DOC, DOCX

📝

IRS Letter

PDF, DOC, DOCX

📄

W9 Form

PDF, DOC, DOCX

✉️

Credentialing Letter

PDF, DOC, DOCX

🏆

Board Certificate

PDF, DOC, DOCX

📎

Additional Supporting Documents

Optional - Multiple files allowed

Insurance Networks Select all that apply

UnitedHealthcare

Aetna

Cigna

Humana

Kaiser Permanente

Blue Cross Blue Shield

Centene

Molina Healthcare

Health Care Service Corporation

Elevance Health

WellCare

CareSource

Highmark

Independence Health Group

GuideWell

Medicare

Medicaid

Tricare

Blue Shield

Ambetter

Other / Custom

Service Fee Selection

Select the services you require:

Government Insurance - $150

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Commercial Insurance - $100

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EDI/EFT - $50

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Re-Credentialing Insurance Payer - $100

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NPI Creation - $150

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CAQH Creation - $200

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Labour Licensure - $300

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Labour Accreditation Letter - $300

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Labour Mal Practice - $250

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Total Fee: $0