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Signing a Contract

Credentialed Member

Complete the below form to apply as a credentialed member.  Initial credentialing dues are $500 per provider and will be applied to the annual provider dues.  Please reach out to the JPG office with questions or if you require a paper application.

Credentialed Member Application

Payer Plan Information

Do you accept the following?

Directory Information

Are you a...
Have you received cultural training?
Do you provide Tele-Med Services?
Check All that Apply
Check All that Apply
Patient Age and Gender Limits

Practice Location Information

Primary Practice Address 

Credentialing Address 

24 hour 7 day a week phone coverage

Billing Address 

Correspondence Address 

Do you want the practice location listed in the directory?
Which of the following facilities meet ADA Accessibility Standards?
Is this location accessible by public transportation?

Please download, complete and upload the following documents

Download Payer Enrollment Form
Upload File
Upload File
Upload File
Upload File
Upload File
Upload File
Upload File

OR

Thank you! We’ll be in touch.

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