HomeFor ProvidersApplication

Request for Application

Thank you for accepting your invitation to apply to OneCare. OneCare is an Exclusive Provider Organization (EPO) and requires all providers to complete an application, undergo primary source verification, and be approved by the OneCare Credentialing Committee and Board of Managers.

Credentialing Process
  • The first step in this process is to complete a Request for Application form.
  • Receipt of this information is a prerequisite to be considered for further application processing.
  • Please be sure to include an email address where indicated on the Request for Application form.

For Additional Information
If you have questions or would like to receive additional information, please call 812-450-7265.

Provider Information

Application Code:
Completed By:
Date Completed:
Provider's First Name:
Last Name:
MI:
Provider's Date of Birth:
Provider's Start Date:
Credentials:

























TIN:
Individual NPI:
Primary Specialty:
Secondary Specialty:
Practicing Specialty:
Supervising Physician:
Board Certified?
Board Name:
Registered with CAQH?
CAQH ID:
Is Provider Joining an Existing Practice:
Does provider currently have a permanent state license, CSR(if applicable), and DEA (if applicable) for the state in which he/she will practice?

Practice Information

Practice Name: (Please indicate the name of the practice you will be joining.)
Street:
City:
State:
Zip:
County:

Application Correspondence Information

Street:
City:
State:
Zip:
Phone:
Fax:
Contact Person:
Contact Person Email:
Contact Phone:

Additional Information

Comments:

I understand that completion of a Request for Provider Application does not guarantee participation in the OneCare network.


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