Please download and fill out the following forms:
- Interest form
- W9
- Roster
- Practitioners Credentialing Application
Facilities and Hospitals Credentialing Application
(You may download a copy of your CAQH and send to us in lieu of a credentialing application.)
Once your interest packet has been received, we'll start reviewing your request to become a participating provider. You'll be assigned a representative who will give you some next steps in the contracting process, like reviewing your current credentialing status.
You can return all forms to: IDcontracting@PacificSource.com