Provider Recredentialing Form

Nationally recognized quality standards require behavioral health providers to recredential every three (3) years. Periodically reviewing and verifying your professional credentials helps MHC maintain current information allowing us to offer referrals that will best match the needs of our members to your specialties. Please take a few minutes to complete this recredentialing form.

Prior to starting, please have the following information or documents available:

  • State License(s) (Psychiatrists, Registered Nurses, and Physican Assistants must include DEA license)
  • Face Sheet of Professional Liability Insurance (include CAT Fund information if applicable)
  • W-9/Tax ID Number

If you are contracted with MHC under more than one Tax ID Number, you will need to submit a separate recredentialing form for each tax id.

Questions regarding this form should be directed to MHC Provider Relations- providerrelations@mhconsultants.com.

Provider Recredential Form
Provider Name
Provider Name
Title
First
Last
I certify by checking the box below my liabiliy/malpractice insurance is up to date:
Primary Practice Address
Primary Practice Address
City
State/Province
Zip/Postal
Country
My Primary Practice Address is
Preferred Communication Type
Is your primary mailing address the same as your primary practice address?
Primary Mailing Address
Primary Mailing Address
City
State/Province
Zip/Postal
Country
Is the primary payment address the same as your primary practice address?
Primary Payment Address
Primary Payment Address
City
State/Province
Zip/Postal
Country
Do you have a secodary practice location under your Tax ID #?
Secondary Practice Address
Secondary Practice Address
City
State/Province
Zip/Postal
Country
My Secondary Practice Address is
Do You Accept Any of these Insurances?

Maximum file size: 10.49MB