Beacon Health Credentialing Forms

Beacon Health Credentialing Policies – Official credentialing policies and procedures for contracted network providers to participate in the Beacon Health provider network.

Provider Data Form – use this form to notify Beacon Health of a new provider (MD, DO, NP) to be included under a new or existing contract.

Beacon Health Contact Information Form – fillable  –  Use this form to advise and update Beacon Health about the various staff at the practice or facility and their roles, so that we can contact the correct staff for any issue. 

Change in Practice Form – Use this form to notify Beacon Health of any changes of address, identifiers (e.g.: Tax ID, NPI or other numbers) or other practice details.

DEA Attestation for Provider not Prescribing – Use this form to document the prescribing arrangement for any provider who does not prescribe, or have a DEA certificate (required by NCQA for credentialing).

NPI-2 In System Benefit Form – Use this form to notify Beacon Health of the unique NPI-2 number that your practice will use to trigger In System levels of payment when your procedures are performed at an EMHS System hospital.

Contracted Non-Credential Provider Data Form – Use this form to set up contracted network providers that do not require full credentialing review, but where billing for their services will be under the individual provider name.