Credentialing Specialist of America


	Tell Us About You

Thank you for your interest in CSOA Solutions, Inc. If you would like to receive further information, including a price quote, please complete all of the information below and a CSOA representative will contact you within 24 hours.


Company Information:
Name
Address
City
State
Zip Code

Contact Person:
Name
Title
Phone
E-mail

Type of Service Needed (please check all that apply):		Provider/Group Credentialing Application Prep and Submission to Health Plans, Medicare, etc.
		Primary Source Verifications Practitioner Credentialing and/or Recredentialing (NCQA, AAAHC, The Joint Commission, etc.)
		Facility Credentialing SNF, Home Health Agencies, Hospitals, Free Standing Centers
		Updating of Expiring Elements Including License, DEA, Malpractice Insurance, Board Certification, etc.
		On-Going Monitoring of Sanctions State License and Medicare Sanctions
		Consulting

Type of Organization (please check all that apply):		HMO
		PPO
		Hospital/Surgery Center
		Medical Group/IPA
		MSO
		Workers Compensation Network
		Specialty Network

Number of Providers (please select one):

Special Comments or Deadlines to meet:

How did you hear about us?		Google Web Search
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		Referral
		Mailer
		Other

CSOA Solutions, Inc.

Ph: 832-328-2230

www.csoamerica.com
sales@csoamerica.com