Pre-Activation Credentialing & Compliance Consent (PMHNP – 1099 Telehealth)

Candidate Identity Confirmation

This form is used to collect information required for credentialing, background screening, and system access readiness. Completion of this form does not constitute an offer of employment or guarantee clinical assignment or billable work.
Write none if no Middle Name
MM/DD/YYYY (Required for background screening and credentialing)
Gender
This infomation is collected for administrative and credentialing purposes only.
Enter the last 4 digits only (numbers only)
Email
State(s) of Active Licensure
Select all states where you currently hold an ACTIVE, unrestricted license. ***Select N/A ONLY if you are NOT licensed in any of these STATES and are OUTSIDE the US (that is Canada or Overseas)***
Enter license number (if applicable)
Please enter your license expiration date
Please enter your DEA License number if you have one.
10-digit National Provider Identifier
CAQH ProView Provider ID

Required References

Please provide three (3) references as outlined below. Completion of this section is required to proceed with background screening and credentialing.
Full Name
Examples: Supervisor, Medical Director, Colleague, etc
Organization name, City, State
Full Name
Example: Mentor, Friend, Community Leader, etc
Full Name
Examples: Mentor, Faith Leader, Community Leader, etc
Prescriptive Authority Agreement (PAA): I understand that additional state-specific prescribing requirements may apply. If I choose to prescribe, and where required by state law, such requirements must be independently secured by me.
Consent: I authorize SacredHLI to verify my professional credentials, access my CAQH profile, contact my references, and submit required information to payer networks for credentialing and compliance purposes. Background checks may be conducted as required by law or payer policy.
Headway Credentialing: I agree to participate in telehealth activation workflows including Headway if applicable.
Google Calendar Delegation: I agree to share my Google Calendar with SacredHLI scheduling staff using "Make changes to events" permissions and maintain updated availability.
Telehealth Profile Materials: I agree to provide operational materials including headshot, bio, malpractice insurance, and scheduling availability as requested.
Operational Readiness: I understand this form supports credentialing, scheduling, telehealth activation, and operational readiness workflow.

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