Credentialing
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
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
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
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
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
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
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
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
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
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
Applied Behavior Analysis (ABA) Service Area Information
Other healthcare professionals who provide ABA services should complete this form to help us understand the counties in which center-based and/or in-home ABA services can be provided. ID: 40096
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
Disclosure Statement: Individual Practitioners and Groups of Practitioners
Individual practitioners and group practices seeking to join our Horizon NJ Health network must complete this form in compliance with state and federal guidelines. ID: 40097
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