Central California Alliance For Health

 

Provider Credentialing Applications and Forms

Physician Provider


• Allopathic Physicians (MD)
• Osteopathic Physicians (DO)
• Podiatrist (DMP)


Non-Physician Medical Practitioner


• Physician Assistant (PA)
• Nurse Practitioner (NP)
• Certified Nurse Midwife (CNM)
• Certified Registered Nurse Anesthetist (CRNA)


Allied Provider


• Physical Therapist
• Occupational Therapist
• Speech Therapist
• Audiologist
• Hearing Aid Dispenser
• Optometrist
• Acupuncturist
• Chiropractor


Organizational Provider

• Ambulatory Surgical Center (freestanding only)
• Home Health Agency
• Hospital (all types)
• Skilled Nursing Facility/Long Term Care
• Hospice
• Sleep Center/Sleep Lab (freestanding only)
• Acupuncturist
• CBAS (ADHC)


Durable Medical Equipment Provider


Outpatient Laboratory Provider


Transportation Provider


Locum Tenens Notification Form

Please fill out the Locum Tenens Notification form. Locum tenens are providers who temporarily take the place of, or cover, for another provider. All locum tenens who render services to the Alliance members must be disclosed to the Alliance's Provider Services Credentialing staff before providing care to Alliance members. Please fill out the Locum Tenens Notification form for all locum tenens prior to their starting at your practice.


 

 

 

 

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