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Paper credentialing

Forms

  • Application checklist (PDF)
    Fax all applicable items on this checklist to 1-877-759-6221. Or, you may scan your signed documents and submit them by secure e-mail. Please be sure to scan this checklist and fax or email it along with the documents.
  • Credentialing application (PA standard application)
    Completing and/or submitting the Keystone First credentialing application does not guarantee participation in the Keystone First provider network
    Note: If you are joining an existing Keystone First participating group or healthcare facility and you would like to become a participating provider, please use the application above.
  • Credentialing warranty attestation
  • W-9 form 

Documents and information