DMI Provider Credentialing Intake Form

Thank you for choosing Dynamic Marketing Investments (DMI) for your credentialing and enrollment needs.

Please provide the information below as completely as possible. DMI will use this information to establish your credentialing file and prepare the appropriate applications. Additional information may be requested when required by a specific payer, program, provider type, or state.

Practice / Organization

Application Type *

Business Legal Name *

DBA / Practice Name *

Federal Tax ID / EIN *

NPI *

Primary Provider Type / Service *

Specialty

Telehealth Offered? *

Yes

Primary Contact

Contact Name *

Social Security Number *

Email *

Phone *

Date of birth

Address

Street Address

Country

State

City

Postal Code

Education, Training & Hospital Affiliates

Medical / Professional School & Graduation Date *

Internship / Residency / Fellowship & Dates *

Hospital Affiliations / Privileges & Dates *

Credentialing Request

Enrollment Type *

Licensing & Credentials

License Type *

License Number *

Issuing State

Expiration Date

Additional State Licenses

Yes

DEA Registration *

Yes

DEA Number / Expiration (If Applicable)

Board Certification *

Yes

Not Applicable

Board / Certificate # / Expiration

Disclosure / Credentialing Questions

For each item below, check Yes or No. If Yes, provide an explanation and supporting documentation

Any professional license or certification restricted, suspended, revoked, or subject to disciplinary action? *

Yes

common.other_option

Any malpractive claims, settlements, judgements, or pending claims? *

Yes

common.other_option

Any Medicare/Medicaid or other payer sanctions, exclusions or adverse actions? *

Yes

common.other_option

Any criminal conviction relevant to professional practice? *

Yes

common.other_option

Any impairment or conditions that currently affects ability to practice safely? *

Yes

common.other_option

Any gaps in employment or clinical practice requiring explanation? *

Yes

common.other_option

Required / Supporting Document Checklist

Document Upload

Please upload any and all supporting documents listed below:

Current CV / résumé (complete work history with month/year dates)
State professional license(s)
DEA certificate (if applicable)
Board certification / specialty certificate (if applicable)
Malpractice face sheet / certificate of insurance
W-9 / IRS documentation as requested
CAQH profile completed and attested
Medicare / Medicaid enrollment documentation (if applicable)
Hospital privileges / affiliation documentation (if applicable)
Government-issued identification (if required by payer)
Other payer-specific forms or documents

Please upload the documents currently available. DMI will identify any additional documents required for your specific credentialing application.

Client Authorization & Acknowledgment

I authorize Dynamic Marketing Investments (DMI) to use the information provided in this form to evaluate, prepare, and assist with my provider credentialing and enrollment needs. I authorize DMI to request additional information and documentation from me or my organization as necessary to complete the credentialing process. I certify that the information provided is accurate and complete to the best of my knowledge. I understand that credentialing and enrollment decisions are made by the applicable insurance payer, government program, or credentialing organization, and that DMI cannot guarantee approval or a specific processing timeframe.