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QualiT Credentialing

Credentialing Client Onboarding Questionnaire

  1. Business Information

Agency Type
Skilled
Non-Skilled
Both

  1. Contact & Authorized Representatives

  1. Credentialing Services Requested

Please check all services you're interested in

  1. Licensing, Certification, & Accreditation

  1. Ownership & Disclosure

Has any owner or manager ever been excluded from Medicare/Medicaid?
Yes
No
Has any owner or manager ever been convicted of a felony or fraud?
Yes
No

  1. Required Documents Upload

  1. Expectations & Authorization

Are you currently working with another credentialing firm?
Yes
No

By signing below, you authorize QualiT Credentialing to act on your behalf for credentialing and enrollment services.

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