Please download, complete and return the following forms if applicable
Physicians and Dentists
- Continuity of Care Coverage Agreement (COC)
- Required for MD, DO, DMD and DDS who do not have hospital admitting privileges or have chosen to limit their practice to providing services in the office only
- Not required for: allergist/immunologist, anesthesiologist, derma pathologist, dermatologist, emergency medicine, ophthalmologist, pain management, pathologist, physical medicine and rehabilitation, psychiatrist, radiation oncologist, radiology, sleep medicine or sports medicine.
- Statement of Arrangement for Controlled Dangerous Substances: Drug Enforcement Agency (DEA) License
- We allow physicians without a current, unrestricted DEA License to satisfy this requirement by establishing an arrangement with another participating physician (who has a current, unrestricted DEA License) to prescribe controlled dangerous substances on his/her behalf.
- We allow physicians without a current, unrestricted DEA License to satisfy this requirement by establishing an arrangement with another participating physician (who has a current, unrestricted DEA License) to prescribe controlled dangerous substances on his/her behalf.
- Statement of Arrangement for Controlled Dangerous Substances (CDS)
- We allow physicians without a current, unrestricted Controlled Dangerous Substances (CDS) Certificate to satisfy this requirement by establishing an arrangement with another participating physician (who has a current, unrestricted CDS Certificate) to prescribe controlled dangerous substances on his/her behalf.
New Jersey Recredentialing Application for all practitioners (includes disclosure questions)
If you are not using CAQH, please download and complete the NJ Recredentialing Application. Available formats:
- MS Word
- Instructions (PDF)
Education Verification Form for all practitioners
Please use the following form to enter your education information and your consent for us to verify your education: Education Verification Form
Ancillary Providers
If you would like to complete and submit the credentialing application online, click here.
If you are not using the online application, please download and complete the Ancillary Recredentialing Application and supporting documents
- Ancillary Recredentialing Application
- Ancillary Behavioral Health Credentialing Application
- Americans with Disabilities Act (ADA) Provider Survey
- Ownership and Disclosure Statement: Hospital and Ancillary Providers
If you have multiple locations for a single Ancillary Recredentialing Application, please use the following roster template (Note: The roster template should only be used for locations sharing the same NPI and TIN)
Returning the Docs
Completed and signed paper forms may be submitted to andros:
- By Email to credentialing@andros.co
- By Fax to 1-877-437-2909
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