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(09) Credentialing - Provider Information Collection Form


This form is an example of the information you need to collect from a provider (when they start)  that works for your health department. This allows you to collect all the needed information for contracting and credentialing process. Please note that this is a template and it can be modified for your jurisdiction.

Primary Toolkit:

Billing for Clinical Services

Keyword Area:

Billing, Contracting, Credentialing, Immunization


Institutional Author:

Toledo Lucas County Health Department





The NACCHO Toolbox is a repository of available resources to help local public health practitioners. Tools are produced by local, state, and federal agencies, as well as academic institutions and other stakeholders. The contents of this Toolbox are solely the responsibility of the authors and do not necessarily reflect any official recommendations of NACCHO. NACCHO makes no express or implied warranty with respect to the contents and disclaims liability for any damages arising from or connected to the use of the material in this Toolbox.