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Provider Credentialing Application

This Secure Form: This secure form is used to gather information about you so that DBN can provide credentialing services to your facility. This form requires personal information, education and training information, licensure and other professional information in detail. Once submitted, you’ll receive a confirmation page of completion. It is important that you either e-mail, fax, or upload all the required supporting documents to complete your application with DBN. When your profile is complete and you have submitted all supporting documents, you will receive notification of profile completion by your credentialing specialist at DBN. Please note: If an item is listed on your CV, then you can skip that data entry element. But be aware that we need complete dates, not just year, for education, training, and certifications.