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Apply with Advanced Care Providers

 

Print & Return

Apply using the included forms below. Click on the form links, documents will appear as PDF’s.  Download, print, complete and return all documents plus a current CV to us by email (mike@acpstaff.com) or fax 323-375-3290.

Required Forms:

ACP Application
Credentialing Check List
Reference Form

If additional space is needed, here are some blank work sheets for you to use:

Practice History
Previous Liability Carriers

The forms here will not pertain to everyone – if you refuse a Hep B imunization or have had a +TB test:

TB Questionnaire
Hep B Declination

 Online

Apply online using our secure application. Follow our easy, step-by-step process where you can complete the application and upload required credentialing documents.

Online Application requires additional forms to be forwarded. Download, print, complete and return all documents plus a current CV to us by email mike@acpstaff.com or fax 323-375-3290.

Required Forms:

Reference Form
Disclosure Release
Background Check: IA MN WI
Credentialing Check List

Transfer credentialing documents quickly and easily from your computer. Send forms required on the credentialing checklist directly to ACP. Credentialing Check List

Phone

Call an ACP representative to apply today!

Deb Sanfilippo

715-892-0392

deb@ACPStaff.com

Mike Tonne

715-661-0030

mike@ACPStaff.com