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CSI Provider Network Application
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Home Health
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(If you are interested in both, please complete a separate form for home health and hospice)
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(Please use business email address)
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Provide full name and addresses of location(s) to be credentialed (please list all that apply):
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Administrator Name
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Administrator Phone
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Administrator Email
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(Please use business email address)
General Business Information
Date Established
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Total Gross Revenue for past 12 months
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Medicare #
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Medicare Certification mo/yr
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Medicaid #
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Tax ID # (TIN)
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NPI #
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Accrediting Organization
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Current Medicare Star Ratings
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Total Average Daily Census
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Average # New Patient starts per month
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Full time employees
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Part time/Per diem employees
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Payer Mix: Traditional Medicare %
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Managed Care %
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Medicaid %
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Other % (please describe)
Does your agency bill electronically?
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Centralized billing
Individual billing by location
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Centralized Intake Authorization
Individual by location
Name of Sub-contracted Billing company, if applicable
Name of Clearinghouse
Confirm your agency can bill electronically through Availity in batch claim format (this is a mandatory requirement).
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PT
OT
ST
HHA
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Any payers NOT accepted, please detail:
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Form Completed by (Name, Title & Company)
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Date Completed
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