Forms

Iowa Statewide Universal Credentialing Application Forms are available in different electronic formats:

  • Electronic Hard Copy (Protected). Save this version in your system to print, fax, or mail as often as needed.
  • Electronic Template (Protected). Complete this form electronically by tabbing through each information item. Save the template in your system and use as often as needed.
  • Electronic Template (Unprotected for Pre-population Purposes Only). This version allows unprotected access to the electronic template versions of the ISUPCA and the ISUPRA for the sole purpose of "pre-populating" the forms with provider information directly from a database program or utility. This would be most generally utilized by large provider groups, a hospital, or a credentialing organization. An ICC agreement must be completed and signed in order to use the ISUPCA and/or the ISUPRA unprotected word template(s); upon receipt of the signed agreement, the document(s) will be emailed to you. Such access does not authorize user to change the ICC's forms in any way. Contact us to proceed

Iowa State Universal Practitioner Credentialing Application (ISUPACA)

ISUPCA Version 1.7 Hardcopy
(Microsoft Word Document)
ISUPCA Version 1.7 Template
(Microsoft Word Document)

Iowa Statewide Universal Practitioners Recredentialing Application (ISUPRA)

ISUPRA Version 1.5 Hardcopy
(Microsoft Word Document)
ISUPRA Version 1.5 Template
(Microsoft Word Document)

Iowa Statewide Universal Facility Credentialing Application (ISUFCA)

ICC Attachment Checklist

This checklist can be a useful tool to help identify additional information that credentialing entities may require along with the ISUPCA.

Statewide Application Attachment Checklist
(Microsoft Word Document)