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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