Trevion Credentialing Intake

Standard Credentialing Request

Submit provider, practice, credentialing, attestation, and supporting documentation for Trevion review.

Provider

Provider Identity

First NameLast NameProfessional Title / DisciplineNPI

10-digit National Provider Identifier.

California License NumberLicense TypeSpecialty / Subspecialty

Practice

Practice Information

Legal Practice NameDBA NamePrimary AddressCity

StateZIP

Phone NumberPrimary Contact NamePrimary Contact Email

Credentialing

Credentialing Information

Credentialing TypeDEA NumberMalpractice Insurance CarrierMalpractice Policy NumberMalpractice Expiration Date

Documents

Required Attachments

CV UploadCurrent curriculum vitae or professional resume.No document selectedLicense UploadCurrent California professional license.No document selectedInsurance UploadCurrent malpractice coverage evidence.No document selected

Attestation

Provider Attestations

I attest that the information submitted is accurate and complete.Material omissions or changes may require additional credentialing review.I authorize Trevion to verify and evaluate the submitted information.This includes credentialing documentation, licensing, insurance, and professional qualifications.

Submission preserves the request and supporting documents for credentialing review.