Credentialing Forms

Beacon Health Credentialing Policies - Official credentialing policies and procedures for contracted network providers to participate in the Beacon Health provider network.

Provider Form - Use this form to notify Beacon Health of the following:

  • New Providers (MD, DO, NP) to be included under a new or existing contract.
  • Any change of address, identifiers (e.g.: Tax ID, NPI, or other numbers) or other practice details.
  • To set up contracted providers that do not require full credentialing review, but where billing for their services will be under the individual provider name.

Beacon Health Contact Information Form - fillable - Use this form to advise and update Beacon Health about the various staff at the practice or facility and their roles, so that we can contact the correct staff for any issue.

DEA Attestation for Provider not Prescribing - Use this form to document the prescribing arrangement for any provider who does not prescribe, or have a DEA certificate (required by NCQA for credentialing).

NPI-2 In System Benefit Form - If you are providing services at more than one location, please use this form and list your multiple service locations. This will help us process your claims at the appropriate tier / level.

When filing a claim form, please use USPS standard formatting for all addresses. What you list.

  • Use second address line for suite number
  • Rendering provider individual NPI goes in box 24J
  • Rendering a group NPI2 goes in box 33a

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