Credentialing Application

Statewide Universal Credentialing Application Forms

The Iowa Credentialing Coalition 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.

ICC's application forms are available in different electronic formats:

• Electronic hard copy:  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.
   
  • ISUPA (credentialing) version 1.4.1:  This is the most current version of the ISUPA credentialing application form, released February 2010. Users should now use this version which, among other things, includes a place for the NPI.
     
  • ISUPRA (recredentialing) version 1.2.1:  This is the most current version of the ISUPRA (recredentialing form), released February 2010. Users should now use this version.

• Electronic template:  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.
   
  • ISUPA (credentialing) version 1.4.1:  This is the most current version of the ISUPA (credentialing form), released February 2010. Users should now use this version which, among other things, includes a place for the NPI.
     
  • ISUPRA (recredentialing) version 1.2.1:  This is the most current version of the ISUPRA (recredentialing form), released February 2010. Users should now use this version.