Maine Carrier Credentialing Extension Application

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×Please Note: This form has room for 10 Provider Applicant Names. As you are adding one, the fields for another will appear in case you have more than one to enter. If you are filing for more than 10 applicants, then you will need to submit another form with the remaining Provider Applicant Names. If the delay is NOT specific to one provider, you must provide a Detailed Remediation Plan. Field names with an * beside them are required. When information for all Provider Applicant Names is complete, press the Submit button.

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If you need to enter more than 10 applicants, please resubmit this form with the rest. Thank you.