Ascentiant Health, an Ascentiant International Company
1341 Distribution Way
Suite 11 - Top Floor
Vista, CA 92081
Credentialing Check List
Agency Name
Agency Type
Agency Specialty
Agency Services
Agency NPI
Agency Tax ID
Agency Medicaid ID
All the information below is necessary to complete the process. Failure to provide requested information will result in delay in verification and approval of your credentialing.
Owner's Information
Name
SSN
DOB
Home Address
Contact
Email Address
Required Documents
Articles of Incorporation or Business Registration
Copy of All Owner IDs
State business license
Signed W-9 Form
Liability Insurance Certificate
IRS (EIN) Letter
Banking Information (Voided Check/Bank Letter)
Location
_________________________________________
Phone
_________________________________________
Fax
_________________________________________
Agency Email Address
_________________________________________
Billing Location
_________________________________________
Mailing Location
_________________________________________
Phone
_________________________________________
Fax
_________________________________________
Ownership Details %
_________________________________________
Co-owner's Information, if applicable
Name
SSN
D-O-B
Home Address
Contact
Email Address
Payer List (check all those required for credentialing)
