Request To Send Application

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Request To Submit Application

  • Date Format: MM slash DD slash YYYY
  • Group/Practice Info

  • Credentialing Contact Info

  • Provider Information

    Additional fee of $615 is required prior to expedited processing. Please submit expedited fee to Katie Degenhardt, Expedited File Specialist, at katiedegenhardt@mprcred.com.
  • Date Format: MM slash DD slash YYYY
    *NON-PHYSICIAN PRACTITIONER CREDENTIALING NOT APPLICABLE

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