Please complete this form so that we may contact you to further discuss your credentialing needs. First Name:   Last Name   Title:     Email: Organization Name: Address: City: State Zip:     Phone:   Fax:       What is your total number of providers to be credentialed? Please enter the types of providers you would like credentialed: (i.e. MD, DO, DDS, PhD, MSW, PA) How many NEW applications do you process each month? Which credentialing standards do you require?   NCQA   JCAHO Other How did you hear about Healthplex Credentials Verification Organization?   NCQA   Internet search Other Subject Message: Healthplex Inc. Attn: Credentialing Department 333 Earle Ovington Boulevard, Suite 300 Uniondale, New York 11553-3608 Phone: 516-542-2212 or 1-800-468-0608 ext 2212 Fax: 516-228-9568 Email: kelly.andron@healthplex.com