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Iowa Credentialing Coalition

Statewide Universal Credentialing Application Forms - September 2006

The ICC has developed three universal credentialing application forms:

• Iowa Statewide Universal Practitioner Credentialing Application (ISUPCA)
• Iowa Statewide Universal Practitioner Recredentialing Application (ISUPRA)
• Iowa Statewide Universal Facility Credentialing Application (ISUFCA)

The ICC also developed an Application Checklist as a useful tool to help identify additional information that credentialing entities may require along with the ISUPCA.

Click here to access the Checklist. (WORD 42KB)

ICC's application forms are available in different electronic formats

• ELECTRONIC HARD COPY (PROTECTED) You may save this version in your own system and you may print, fax, or mail it as often as you need to. Click below to access the forms.
  
  ISUPCA (credentialing) version 1.3 (WORD 260KB)
  This is the most current version of the ISUPCA credentialing application form, released September 2006. Users should now use this version which, among other things, includes a place for the NPI.
  
  ISUPRA (recredentialing) version 1.1 (WORD 171KB)
  This is the most current version of the ISUPRA (recredentialing form), released September 2006. Users should now use this version.
  
  ISUFCA (facility) version 1.0 (WORD 103KB)
  
  
• ELECTRONIC TEMPLATE (PROTECTED). You may complete this form electronically by tabbing through each information item. You may save the template in your system and use it as often as you need to. Click below to access the forms.
  
  ISUPCA (credentialing) version 1.3 (WORD 755KB)
  This is the most current version of the ISUPCA (credentialing form), released September 2006. Users should now use this version which, among other things, includes a place for the NPI.
  
  ISUPRA (recredentialing) version 1.1 (WORD 365KB)
  This is the most current version of the ISUPRA (recredentialing form), released September 2006. Users should now use this version.
  
  
• ELECTRONIC TEMPLATE (UNPROTECTED FOR PREPOPULATION PURPOSES ONLY). This version allows you unprotected access to the electronic template versions of the ISUPCA and the ISUPRA for the sole purpose of "prepopulating" the forms with standard information (i.e., the name, address, telephone numbers of the clinic). You must complete and sign an ICC agreement for use of the ISUPCA and/or the ISUPRA word template(s) after which the document will be e-mailed to you. Such access does not authorize you to change the ICC forms in any way. Contact to proceed.

Please direct any questions that you might have to at (515) 223-1401 ext. 244