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Practitioner Application

This application is for new individual practitioners not currently participating in the CDPHP® network. Individual practitioners who are already credentialed/participating with CDPHP and are requesting an address/tax ID change or other demographic update should complete the Practitioner Information Change Request Form.

To contract with CDPHP as a facility or ancillary provider offering laboratory, durable medical equipment (DME), home health care, home infusion, transportation, imaging, dialysis, hospice, or skilled nursing services, please contact Healthcare Network Strategy at (518) 641-4290 or

If you have any other questions while completing this application, please contact the CDPHP Credentialing Department at (518) 641-3321 or for assistance.

IMPORTANT: The New York State Department of Health requires practitioners – with a few exceptions* – to have a NY Medicaid Management Information System (MMIS) ID number prior to enrollment with CDPHP Medicaid, HARP, or Child Health Plus (CHP). 

To apply for a NY MMIS ID, visit
For questions regarding MMIS, contact Provider Services at (518) 641-3500.

*Exceptions include: Acupuncturist (LAc), Nutritionist/Registered Dietician (RD/RDN), and Orthoptist.

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 midwives must provide a collaborating physician. Nurse practitioners with under 3600 hours of qualifying experience must provide a collaborating physician.
Please select ONLY if the provider is associated with the Eight County Physician Org IPA.
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 identification 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 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 a 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 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.