State Credentialing Forms

Providers in the states listed below may use their state’s form in place of the MultiPlan form for initial credentialing when applying to join our networks or for recredentialing purposes. The forms are posted below for your convenience. (Note that to apply to join our networks, these forms must be accompanied by a completed and signed MultiPlan provider contract.)

If you are interested in joining our networks, please click the “Join Our Network” button at the left to use our online nomination system. If you meet our initial participation criteria, we will send you an application and contract to complete and return to us.

For questions about our credentialing process or joining our networks, call our Service Operations Department at 800-950-7040.

Arkansas	initial credentialing form recredentialing form
Colorado	initial credentialing form
District of Columbia	initial credentialing form recredentialing form
Illinois	initial credentialing form recredentialing form
Kansas	initial credentialing form
Kentucky	credentialing form (1 of 4) (2 of 4) (3 of 4) recredentialing form (4 of 4)
Louisiana	initial credentialing form
Maryland	initial credentialing form recredentialing form
Massachusetts	initial credentialing form recredentialing form
Mississippi	initial credentialing form
Missouri	initial credentialing form
Nevada	initial credentialing form
New Jersey	initial credentialing form recredentialing form
North Carolina	initial credentialing form
Ohio	initial credentialing form
Oklahoma	initial credentialing form
Texas	initial credentialing form
West Virginia	initial credentialing form recredentialing form