Add a New Facility or Practitioner to Existing Agreement

To add a new facility to an existing application, please download and fill out the Facility Credentialing Application (PDF) and upload along with applicable supplemental documents listed on the last page of the application.

To add a new practitioner to an existing agreement, please download and fill out the Practitioner Enrollment Form Template (Excel | .xlsm).

Upload Practitioner/Facility Enrollment Form *

If you are an Atypical Practitioner (Doula, Community Health Worker, etc.), please download, fill out, and submit the Atypical Practitioner Credentialing Application

Please upload a completed W-9 form, if available. *Required for all new facility requests.

Please upload a completed Disclosure of Ownership Form (ODF) that includes the TIN and all GNPIs being submitted in the request. Form should be signed and dated within 1 year of the submission date. *Required for ALL submissions. *

Additional Supporting Documents (for Atypical Providers)

If you have more than one document to upload, please either combine PDFs to one file, or create a .ZIP archive

Enrollment requested by:

First Name: *

Last Name: *

Contact Email: *

Contact Phone Number *

Attestation * I hereby certify the above information to be true and correct to the best of my knowledge.

Note: If you have already completed your application with CAQH, please ensure that you have authorized Meridian to access your data. This can be done by calling CAQH at (888) 599-1771 or by logging into your account and adding Meridian to your list of authorized plans. Using the CAQH Universal Credentialing DataSource does not grant participation or constitute applying for participation with Meridian.

Last Updated: 11/07/2024