Existing Provider Enrollment for Credentialing Maintenance

Dentist Information
Licensing & Professional Info

Dental License

Drug Enforcement Administration (DEA) License

I, Dr. do not possess a DEA because: *

In the event a patient needs to obtain a prescription, I would refer them to: *

Professional Liability Information (PLI)

Practice information
Authorization & Consent

By signing below, I authorize CMO Pacific LLC DBA Credentialing Genie to:

  • Access and update my CAQH profile and insurance records.
  • Act on my behalf to maintain credentialing status with insurance carriers.
  • Act on my behalf to maintain credentialing status with insurance carriers.

I understand this service is for ongoing credentialing maintenance only and does not include new payer applications unless agreed upon separately.

I agree to maintain communication and provide any updated documentation needed to ensure continued participation.

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