Central California Alliance For Health


Provider Credentialing Applications and Forms

Physician Provider

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

Non-Physician Medical Practitioner

• Physician Assistant (PA)
• Nurse Practitioner (NP)
• Licensed Midwife (LM)
• 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)
• Freestanding Birth Centers (licensed only)

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 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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