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Credentialing Application checklist Form: What You Should Know

Note: When you get out your health card and driver's license, write down the address for each location where you have worked.  Credentialing Application Checklist — Reclaim Comprehensive 3. Take a photograph or fingerprint to document the identity of yourself.   Photograph only the following items: the photo, a printout of your medical record and two of the three components of your ID: passport, Social Security card, and Medicare Number. Note : Medical and DEA documents will not be accepted as verification of identity. Credentialing Application Checklist — Reclaim Comprehensive A-C · Medical License — Current and valid · Social Security card (original, copy, valid, expired/refused, and all 4 components if different from the photo) · Driver's license (original, copy, valid, expired/refused, and valid photo) · Current Utility Bill · Photo ID (driver's license or passport) D-G · DEA LIC # — original, copy, and invalid (if expired) · Photo ID (driver's license or passport) · Current Utility Bill · Photo ID (driver's license or passport) E-H · Medicare Identification Program Number · Department/State issued document (original, copy, expired/refused, and valid) · Medical License (original, copy, valid, expired/refused, and valid photo) · Utility Bill · Photo ID (driver's license or passport) I-J · Medical License — Current and valid · Photo ID (Driver's license or passport) · Medical/Prescription Drugs (original, copy, expired/refused, and valid) · Driver's License (Original, copy, valid, expired/refused) If you are having difficulty with one of your documents, contact Inland EMP Credentialing at or at imhealthcareicomcredentialing.com.

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