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
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
Statement of Collaboration
Certified Nurse Midwives, Certified Registered Nurse Anesthetists, Advanced Practice Nurses and Physician Assistants use this form to establish a consultative, collaborative management and referral relationship with an appropriate participating physician. ID: 5712
Provider Network Special Needs Survey
A copy of this survey must be completed by physicians (MD/DO) and other healthcare professionals who are seeking to join Horizon NJ Health networks. ID: 32210
Behavioral Health Practitioner Supplemental Information
Behavioral Health practitioners use this form to provide information about their practice as part of the credentialing process as well as to help us make clinically appropriate referrals. 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
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 (1219)
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
