Central Verification Office Application Request

Please fill out the following information to receive your credentialing application and materials. If you do not have a CAQH ID, please email the Premier Health Central Verification Office directly or you can request a CAQH ID.

Name *

CAQH ID *

Email *

All materials and communications will be sent to this email address.

Mobile Phone *

Provider Group Name *

Credentialing Contact

Please select your role *

Please select your title *

Specialty *

Are you currently credentialed at a Premier Health hospital? *

Primary Hospital *

Anticipated start date *

Were you credentialed within the last six months? *

Select Secondary Hospital(s) if desired

Note: If your credential date is more than 6 months in the past, you will be charged an additional fee for adding a secondary hospital.

Initial Credentialing at an additional Premier Health hospital

Note: If your credential date is more than 6 months in the past, you will be charged an additional fee for adding a secondary hospital.

Recredentialing/Annual Fees at a Premier Health hospital

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