Any organizational provider interested in participating in our networks must complete the credentialing application below. Upon completion of the Organizational Provider Credentialing Form, take the following steps:
- Save the application form, which includes your electronic signature, on your computer.
- Send an email and attach the completed form and any supporting documentation.
- Please complete a separate application for each provider type or service.
What to expect
Within three (3) days of receiving your credentialing application form, we will send an email confirmation to you and forward the application to our Credentialing Committee. When your credentialing application form has been approved by the Credentialing Committee, we will send you a provider agreement. Please note that your provider participation is not effective until a mutually executed provider agreement is in place.
Acceptance of your application and the subsequent execution of a contract may result in you being listed as a network provider in one or more of our provider directories.
Independence does not guarantee a minimum volume of services to any network provider.
The following organizational provider networks have limitations to participation:
Durable medical equipment
The durable medical equipment network is closed to new providers except when the provider offers exclusive, medically necessary services that cannot be obtained elsewhere.
There is no waiting list for durable medical equipment providers.
The clinical laboratory network is closed to new providers in the Philadelphia five-county region and its contiguous counties (i.e., the counties that surround the Independence service area) except when the provider offers exclusive, medically necessary testing that cannot be obtained elsewhere.
There is no waiting list for clinical laboratory providers.
Organizational provider demographic updates
If you have a change to your demographic information, please complete the Organizational Provider Demographic Change Form.
Updates can be made to the following information:
- Facility name
- Provider type
- Mailing address
- Tax Identification Number
- Phone number
- Fax number
- Billing address
- Contact person’s name
- Contact person’s phone number
- Contact person’s email address