Skip to main content
COVID-19

Credentialing

PDF  Physician Application Checklist

Physicians (MDs and DOs) must complete this form to help ensure that all information/documentation is included in a request to join our networks. ID: 32214

PDF  Other Healthcare Professional Application Checklist

Other healthcare professionals (who are not MDs or DOs) must complete this form to help ensure that all information/documentation is included in a request to join our networks ID: 32244

PDF  Participation Application for Telemedicine-Only Practitioners

Practitioners who limit their practice to ONLY providing telemedicine services may submit this form to request to join our network(s). ID: 40022

PDF  Hospital-Based Practitioners

Physicians and other healthcare professionals who are affiliated with a hospital-based practice may use this form to join our networks. ID: 32255

PDF  Continuity of Care Coverage Agreement

Physicians who limit their practice to providing services only in their office use this form to advise us of an established arrangement with other participating physicians/groups to care for patients requiring acute care at a network hospital, thereby satisfying our credentialing requirement to have network hospital privileges. ID: 5714

PDF  Special Needs Information: Medical Practitioners

Medical Practitioners should complete this from to help us understand the level of training and/or experience you have treating patients with special needs. ID: 32210

PDF  Special Needs/Supplemental Information: Behavioral Health Practitioners

Behavioral health Practitioners should complete this form to help us understand the level of training and/or experience you have treating patients with special needs. ID: 32443

PDF  Statement of Arrangement for Controlled Dangerous Substances NJ CDS Certificate

Prescribers without a current, unrestricted DEA License use this form to document their arrangement with another participating physician to prescribe controlled dangerous substances on his/her behalf. ID: 5005

PDF  Statement of Arrangement for Controlled Dangerous Substances Drug Enforcement Agency (DEA) License

Prescribers without a current NJ CDS Certificate use this form to document their arrangement with another participating physician to prescribe controlled dangerous substances on his/her behalf. ID: 5006

PDF  HIPAA 5010 Address Information

Practitioners seeking to participate in the Horizon NJ Health Network use this form to document the service address, billing address, and remit address information for each location at which they practice. ID:30500

PDF  Americans with Disabilities Act (ADA) Provider Survey

A copy of this survey must be completed for each location at which a participating Horizon NJ Health physician/other healthcare professional will practice. ID: 32209

PDF  MAT/OBAT and Navigator Attestation

Practitioners who provide Medication Assisted Treatment or Office Based Addiction Treatment service must complete this form to attest that they are in compliance with all state guidelines/requirements. ID: 40070