Credentialing Support — ClinixMatch

Section 1: Provider Identity

What type of support do you need?*

Full Legal Name*

NPI - 1 (Individual)*

NPI - 2 (Group)

Provider Type*

NP MD DO PA

Primary Specialty*

Please specify other specialty

Email Address*

Phone Number*

Section 2: Practice Information

Practice / Group Name*

Practice Address*

Practice Phone Number*

Tax ID

Billing Structure*

Individual Group

Section 3: State & Compliance

Supervising / Collaborating (if applicable) Physician Name

Supervising/Collaborating Physician (if applicable) NPI

Type of Agreement with physician (if applicable)

Collaboration Supervision

Delegation Agreement in Place?

Yes No N/A

Prescriptive Authority?

Yes No

Years of Experience

If in California, have you completed the California transition to independent practice requirement? (If applicable)

Yes No Not sure

Section 4: Credentialing Information

CAQH ID

CAQH Username

License 1 - Number*

License 1 - State

License 1 - Expiration Date

License 2 - Number

License 2 - State

License 2 - Expiration Date

Section 5: Insurance Information

Do you currently have malpractice insurance?*

Malpractice expiration date

Section 6: Enrollment Preferences

Please specify other insurance

Desired Effective Start Date*

Urgency Level*

Standard Expedited (additional fees apply)

Section 7: Document Uploads

Please upload LicenseClick to upload (PDF, JPG, PNG)

Section 8: Attestation

I certify that the information I have submitted is accurate and complete to the best of my knowledge. I understand that Wholesome Collaborations may request additional documents or information to support credentialing, payer enrollment, or onboarding. *I consent to being contacted regarding credentialing, enrollment, and onboarding services. *