- Credentialing application (PDF) (Pennsylvania standard application)
Completing and/or submitting the Keystone First credentialing application does not guarantee participation in the Keystone First provider network.
Note: Use this application if you are joining an existing Keystone First participating group or health care facility and you would like to become a participating provider.
- Practitioner 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.
- Organizational/facility application checklist (PDF)
- Organizational/facility credentialing application (PDF)
- Ownership and control disclosure form (PDF)
- IRS Form W-9 (PDF)