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Onboarding Questionnaire
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QualiT Credentialing
Client Intake Form
Date
Agent/Representative Name
Company Name and D.B.A.
Corporation Type
Company Information
Corporate Phone/Toll Free
Website
Hours of Operation
Address
Tax ID
NPI
Current Services Provided
Requested Services
Enrollment
Credentialing
Contracting
Re-Credentialing
Are you in enrolled in Medicare?
Yes
No
PTAN & Effective Date
Are you accredited?
Yes
No
Accreditation Type & Effective Date
Are you enrolled in the State Medicaid Program?
Yes
No
Medicaid ID & Effective Date
Previous Customer?
Referred by
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Client Intake Form
Onboarding Questionnaire
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