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Med Advantage Information Request Form
Request for Credentialing/Proposal Information

In order for us to provide you with an online proposal, please complete the following questionnaire and "submit" to Med Advantage. If you wish to request a proposal without completing this online questionnaire, please email your request to sales@med-advantage.com.

Bolded questions are mandatory fields

Type of Request:	Information only Information & Proposal Proposal only
Organization:
Contact Name:
Title:
Address:
City:
State,Zip:
Phone:
Ext:
Fax:
Email:

	Type of organization:
	HMOPPOMCO BHOIPAHospital Other(Please specify below)

	Type of Service Requested:
	Primary Source Verification for Credentialing/Recredentialing On-line Verification for Credentialing/Recredentialing(MD & DO only) Fax Verification for Credentialing/Recredentialing

	Type of Practioners to be Credentialed/Recredentialed:
	Physicians Allied Health Behavioral Health Other (Please specify below)

	Number of Practioners to be Credentialed/Recredentialed:
	Less than 100 100 to 500 501 to 1000 More than 1000

	Type of Credentialing Needed:
	NCQA 2000 NCQA 2001 Standard (No hospital or insurance verification) The Joint Commission Other (Please specify above)

	Please send proposal/information to contact person above by:
	MailEmailFaxPhone
	Special Circumstances or Deadlines: