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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.

ATTENTION: Credentialing may not be required for practitioners providing additional coverage due to the COVID-19 pandemic. Please contact Provider Relations at (518) 641-3890 or email ProviderRelations@cdphp.com PRIOR to completing an application.

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)
Physician Assistants must provide a supervising physician, Nurse Practitioners and Nurse Midwives must provide a collaborating physician.
Maintenance Manager Information System (MMIS) is a number assigned by the state when providers enroll with NY Medicaid. It is required in order to serve CDPHP Medicaid, HARP and Child Health Plus (CHP) members The following provider types are not required to have an MMIS ID: • Licensed Mental Health Counselor (LMHC) • Licensed Marriage and Family Therapist (LMFT) • Providers in group practices that do not participate with State Programs
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).
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.

Practitioner Primary Service Address

Credentialing Contact

Affiliated with (Check any that apply):

Mailing Address (if different than above)

Does the practitioner appear on the Medicare Opt-Out listing for his/her state?
Please indicate if the practitioner provides specialized HIV/AIDS related care
Please indicate if the practitioner holds the above certification AND is currently in practice as an certified Lactation Counselor.
Medication-assisted Treatment (MAT) is the use of medications, in combination with psychosocial treatment and supports, to provide a whole-person approach to the treatment of substance use disorders. MAT is clinically driven with a focus on individualized patient care. See www.oasas.ny.gov for more information

- The Practitioner/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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