JNM Healthcare Solutions

Credentialing Intake Form

At JNM Healthcare Solutions, we provide fast, accurate, done-for-you credentialing and provider enrollment services. We take the stress out of paperwork so you can focus on your practice.

Please complete the questions below to determine the best package for your needs.

First Name *

Last Name

Phone *

Email *

Are you credentialing as an individual provider, a group practice, or both? *

Individual Provider

Group Practice

Both

What is your specialty and provider type? (Example: FNP, PMHNP, LCSW, LMFT, LPC, MD, DO, etc.) *

Do you already have your NPI(s), CAQH profile, EIN, and LLC/PLLC set up? *

Which state(s) do you need credentialing in? *

Do you already have a business office address in that state?

How many providers are you credentialing? *

Which insurance payors do you want to credential with? *

Will you need billing setup support as well, or just credentialing? *

When would you like to begin credentialing? *

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Nerissa Malloy LLC