Providers

Remember to contact us any time you have changes to your credentials or demographic information. You can use the forms below to contact us for some of the most common reasons.

Provider Termination Form - Use when a provider leaves your group or if you are closing your practice.

Provider Address Change Form - Use when you are relocating your practice, have a new office manager, or are changing your billing or credentialing address. Also used if you are adding a secondary location.

Provider Practice Change Form - se when you are leaving one practice and forming a new practice or joining another group.

Provider Name Change Form - Use this form only when a name change for a provider has occurred.

 

Credentialing Forms

The following forms are used for Health Plus Credentialing/Recredentialing.

Notice of Applicant Rights

UnityPoint Health Plus Attestation Statement

UnityPoint Health Plus Agreement

State of Illinois Credentialing and Data Gathering Form

State of Illinois Recredentialing and Data Gathering Form

Credentialing Checklist of Required Items

Recredentialing Checklist of Required Items



UnityPoint Health Plus follows NCQA criteria for credentialing and recredentialing of providers and follows the State of Illinois Single Credentialing Cycle for the recredentialing of providers as mandated in 410 ILCS 517 Health Care Professional Credentials Data Collection Act. Providers are recredentialed based on the last digit of their Social Security Number according to the State of Illinois Cycle. All providers are required to use the State of Illinois Credentialing and Recredentialing forms as UnityPoint Health Plus does not use and has no access to CAQH.

For additional Credentialing questions, please call Provider Relations at (309) 671-8231.