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- firstname.lastname@example.org.