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Credentialing
Please read before continuing: Unless you are currently a contracted provider for South Country Health Alliance (SCHA), the information on this page does not pertain to you. If you are interested in becoming a contracted provider for SCHA, please complete the Provider Contract Application (.doc) form. Instructions for submission are on the form. Thank you!
South Country Health Alliance is now part of the Minnesota Credentialing Collaborative (MCC).
Instructions: Minnesota Uniform Provider Credentialing Form
- Download and print the Practitioner Credentialing Application (pdf) or complete the online form version (.doc).
- Fill out the form. Please type or print legibly using blue or black ink.
- Fax, mail, or email the completed form to:
Jeanette Garcia
P.O. Box 463
Brainerd MN 56401
218-316-3180
Fax: 218-270-3003
jgarcia@mnscha.org
Important Tips to Complete the Credentialing Process as Quickly and Efficiently as Possible:
- Credentialing applications should be submitted at least 90 days prior to the date the practitioner intends to start providing services to SCHA members. SCHA needs sufficient time to complete the credentialing process.
- All applicable sections of the application must be completed.
- All dates must be in month and year format.
- Unless the practitioner has recently completed their education, a five year employment history is required. Gaps of more than three months must be explained.
- A current copy of the practitioner’s MN license, DEA registration (if applicable), and certificate of malpractice liability insurance must be submitted with the application.
- The malpractice insurance certificate must list the practitioner’s name (in typed format), amount of coverage, and expiration date. If the practitioner’s name is not listed on the certificate, a statement on clinic letterhead listing the practitioners that are covered by the policy is required.
- All signature pages of the application should be dated within 30 days of submitting the application to SCHA.
Practitioners Rights and Notification
- Each Provider shall have the right, upon written request, to review his or her Credentialing file, except for information that is privileged or protected from such disclosure, and to submit corrective statements with respect to the initial application. SCHA or its TPA will place the corrective statement in the Provider’s Credentialing file, but this does not require SCHA or its TPA to alter or delete any information contained in the file.
- Practitioners shall be informed of any information discrepancies, and shall have the opportunity to correct any erroneous information gathered during the credentialing process, prior to review by the Credentialing Committee.
- Practitioners, upon request, shall be informed of the status of their credentialing or recredentialing applications.
Additional Credentialing Forms