Credentialing Intake & Authorization

Practice Information

Practice Legal Name *

DBA (if applicable)

Tax ID (TIN) *

Practice NPI (Group NPI, if applicable)

Primary Practice Address *

Additional Locations (if applicable)

Primary Contact Name & Title *

Primary Contact Email *

Primary Contact Phone *

Provider Information

Add one row per provider. Upload a government-issued photo ID for each — it will be attached directly to the deal in our CRM.

Additional documents needed per provider (send separately or upload later): Current CV · Active state license(s) · DEA Certificate (if applicable) · Board certification(s) · Malpractice Insurance COI · W-9 · CAQH ProView access · PECOS access (if applicable)

Credentialing Structure

Enrollment type (required)

Individual Provider Enrollment Only Group Enrollment Only Both Individual and Group Enrollment

Most setups require group + individual enrollment so billing flows correctly. Individual-only may apply for MSO models or independent providers billing under their own TIN.

If group: Billing under group TIN?

Yes No

Individual reassignment to group?

Yes No

States for Enrollment

List all states where credentialing is requested *

CAQH Profile

Existing CAQH profile?

Yes No

CAQH ID (if yes)

Authorize Zavisa RCM to access, update, and re-attest CAQH profile as needed?

Yes No

A one-time onboarding/setup fee applies for new providers, which may include CAQH profile creation.

Contract Authority

Who is authorized to sign payer contracts?

Practice will review and sign all payer contracts (default) Zavisa RCM authorized to sign payer contracts on behalf of the practice (written authorization required)

Fee Schedules & Rates

The practice acknowledges that many payers do not release fee schedules until after enrollment approval. Zavisa RCM will collect and document fee schedules when available and retain copies for practice records. Zavisa RCM does not accept or negotiate rates unless separately requested.

I acknowledge the above fee schedule policy

EFT / ERA Enrollment

Authorize Zavisa RCM to assist with EFT and ERA enrollment and updates?

Yes — Zavisa RCM is authorized to assist with EFT and ERA enrollment No — practice will manage EFT and ERA enrollment independently

If authorized, practice agrees to provide required banking and authorization documentation. Zavisa RCM does not store banking credentials beyond what is required for submission.

Credentialing Maintenance (Optional)

Credentialing maintenance begins only after payer enrollments are active

Yes — enroll in credentialing maintenance ($75 per provider/month) No — practice will self-manage ongoing updates and recredentialing

Network Closures & Limitations

The practice acknowledges that some payers may be closed to new providers or practices, and that Zavisa RCM does not control payer network status or approval timelines. If a payer is closed, Zavisa RCM will notify the practice and pause activity for that payer.

I acknowledge the above network closure policy

After submitting your information, you'll be prompted to review and sign the authorization agreement — all in one seamless step.

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