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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  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  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

PDF  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

PDF  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

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