If you are not registered with the Council for Affordable Quality Healthcare (CAQH)* and would prefer to join the Keystone First CHC provider network via our paper process, complete and return the documents linked below. If you have any questions, please call 1-800-642-3510, option 1.
*CAQH credentialing does not apply to HCBS and LTSS providers. HCBS and LTSS providers should complete our paper application process.
HCBS and LTSS providers
HCBS and LTSS provider requests for a contract can be sent to CHCProviders@keystonefirstchc.com. Please include a copy of your W-9, counties that you cover, and services that you provide. A completed contract is required in order to start the credentialing process.
- Application for home- and community-based services and LTSS providers (PDF)
- HCBS/LTSS provider application checklist (PDF)
Physical health practitioners
- Credentialing application (Pennsylvania Standard Application) (PDF)
- Application checklist for practitioners (PDF)
Fax all applicable items on the application checklist, including IRS Form W-9 (PDF), to 1-877-759-6221. Or, you may scan your signed documents and submit them by secure email to firstname.lastname@example.org. Please be sure to scan the application checklist and fax or email it along with the documents.
- Organizational provider credentialing application (PDF)
- Application checklist for organizational providers (PDF)
Completing and/or submitting the Keystone First CHC credentialing application does not guarantee participation in the Keystone First CHC provider network.
Note: If you are joining an existing Keystone First CHC participating group or health care facility and you would like to become a participating provider, please use the credentialing application (Pennsylvania Standard Application) (PDF).