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Practitioner Application

This is for new practitioners requesting to contract and credential with CDPHP. If you are already credentialed with CDPHP® and need to make an address/tax ID change, please use the Practitioner Information Change Request Form. If you have any questions while completing this, please call CDPHP Credentialing Department at (518) 641-3321 for assistance.

The provider is required to register an account with the Council for Affordable Quality Healthcare (CAQH) prior to applying to CDPHP. Please provide the individual ID number you received upon registering.
For social workers working in New York state, your license must have the ‘R’ designation to apply with CDPHP
(Nurse practitioners, Physician Assistants, and Nurse Mid-Wives)
A National Provider Identifier or NPI is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS).
Maintenance Management Information System (MMIS) is a mechanized claims processing and information retrieval system for Medicaid that is required by the federal government.
A Tax Identificaiton number (TIN), also known as an Employer Identification Number (EIN) is a nine digit number that is issued by the internal revenue service. Contact your HR department if you have more questions about how to locate this number.

Credentialing Contact

Practitioner Primary Service Address

Affiliated with (Check any that apply):

Mailing Address (if different than above)

Does the provider appear on the Medicare Opt-Out listing for his/her state?
Please indicate if the provider provides specialized HIV/AIDS related care
Please indicate if the provider holds the above certification AND is currently in practice as an certified Lactation Counselor.

- The Provider/Practice will not seek reimbursement from member for Conversion Therapy Services
- The Practice has a process in place to review managing employees and agents against Federal exclusion lists
You are certifying that your practice has a background check process in place in which providers and employees are reviewed to see if they have any sanctions against them that would place them on the Federal exclusions lists.

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