CONCERN EAP Affiliates Application
Provider Credentialing/Recredentialing
In order to promote the highest quality of care, Concern EAP ensures that all employed and contracted practitioners and providers who join our network meet minimum standards relative to licensure, education, and board certification, if applicable. You are receiving this letter because you either need to go through the initial credentialing process or you are due for recredentialing. We are requesting that you complete the attached Network Eligibility application and send in the needed documentation to complete this process. We appreciate you serving as an affiliate for our company and hope to have a long relationship with you.
If you are applying online, you will need electronic versions (usually scanned and PDFs) of each of the following documents. Please be sure to answer ALL questions and sign/date all forms where indicated. If you are mailing or faxing your application, please return the following items as soon as possible but no longer than 10 business Days:
- Credentialing/Recredentialing Application
- Copy of your current professional license(s) and certification(s)
- Copy of your current Malpractice Insurance Certificate
- W-9 Form, completed
- Resume covering the last 10 years of work history
You may fax your completed application with the above attachments to 901-458-0048.
Or you may mail to:
Concern EAP
Credentialing Dept.
2670 Union Ext., Suite 610
Memphis, TN 38112
You may also e-mail your completed application to: [email protected].
Please be aware that you will be notified of any information obtained during the credentialing/recredentialing process that varies substantially from the information provided in your application, and you have the right to correct erroneous information submitted by another party.
If you have any questions regarding the process, please feel free to call us directly at 901-458-4000.
Electronic Form
The electronic form has five parts. You will submit after each form and will be taken to the next step.