Please note that there are some forms that must be completed before CCNV can proceed with credentialing your file. The below list of blank forms available for download are all REQUIRED unless otherwise indicated. Please download and complete all documents, and attach them on the “Images” tab of the eApply program before submission.
Right-click and “save as” to download the documents below.
Below you will find a list of documents that you will need to submit with your application, as well as the document “type” to select when uploading. Any document that is not received with the application will result in a CCNV staff member contacting your organization to receive them before the credentials verification process can be completed.
PLEASE NOTE: When on the image page in eApply, it will not hyperlink here. Please either print this page or have it open in another window for your reference when completing the image page in eApply.
There is no need to complete the “linked” field on the Images page. (See screenshot, below.) This field is used by CCNV staff ONLY.
Documents marked by an asterisk (***) MUST be received before CCNV staff members are able to begin credentials verification.
If you have any questions, please don’t hesitate to contact us using the contact form at the bottom of this page.
***CCNV authorization and release forms, signed and dated.
***Completed, dated, and signed attestation pages.
Copy of your driver’s license, passport, or any other state or federal photo identification.
Current CV in month/year format. Any gap greater than six months must have an attached explanation for this item to be considered complete.
Copies of current state license(s) for each state in which you practice.
Copy of ECFMG certificate, if applicable
Copy of DEA/CDS certificate(s).
Copies of medical school diploma and resident training certificates.
Letter of hospital coverage arrangements if you do not have current hospital privileges.
Copy of board certification certificate(s).
A copy of current malpractice insurance
Malpractice Claims Information Form(s)
CAQH information and attestation form
Copy of your NPI letter.
For recredialing practitioners, the Recred Quality Report, completed and signed by the medical director.
For nurse practitioners with prescriptive authority, attach practice agreement between NP and Supervising physician as required in 18 VAC 90-4–90 of the Virginia Board of Nursing.
For physician assistants, attach written protocol as required in 18 VAC 85-50-101 of the Virginia Board of Medicine Regulations Governing the Practice of Physician Assistants. Attach a copy of your initial application to the Board and your approval letter from the Board.
For any questions in reference to the application information on this page, or for any questions or issues with the eApply program, please contact an administrator using the contact form below.
Community Care Network of Virginia, Inc
3831 Westerre Parkway | Suite 1 | Henrico, VA 23233 | 804-237-7686