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Contractor Forms

The following forms provided below are essential parts of the credentialing process. Each form can be downloaded as a PDF, printed and completed offline. Click on the form name to take you to the download option.  Complete all requested forms and return to us by email (mike@acpstaff.com) or fax 323-375-3290.

Pre-Contracted Provider Forms:

Credentialing Check List
Reference Form
Background Check: Illinois | Iowa | Minnesota | Wisconsin
HIPAA and Discosure Release 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

Contracted Provider Forms and Training:

Direct Deposit Form
FEIN instructions
Shiftboard Welcome
How to Time Card on Shiftboard

Contact ACP Today

Mike Tonne

715-661-0030 PH
323-375-3290 FX
mike@ACPstaff.com

Advanced Care Providers
PO Box 972
Minocqua WI 54548

Deb Sanfilippo

715-892-0392 PH
323-375-3290 FX
deb@ACPstaff.com

Advanced Care Providers
PO Box 2783
Ormond Beach FL 32175