You will need to:

  1. Complete and submit the applicable re-credentialing application.
    1. If your state is listed below as a state that mandates the use of CAQH, you will also need to complete and submit the Guardian Authorization and Release Form.
  2. If you are participating in our Avesis network of Government programs, you will additionally need to complete and submit a Disclosure of Ownership.
  3. Submit a copy of your valid certificate of insurance.
  4. Submit everything via:

    Email: Re-Credentialing1@glic.com
    Fax: 509.464.8027

1. Recredentialing application

Some states mandate the use of a state specific application or the use of CAQH. If the state in which you practice is listed below, please click on the state to access the applicable application. If you practice in a state that mandates the use of CAQH, you will be directed to the CAQH ProView website. If your state is not listed, please select “All Other States” for the Guardian Credentialing Application.

State Mandated Forms:

Colorado

Illinois

Louisiana

Nevada

North Carolina

Oklahoma

Oregon

Washington

West Virginia

 

CAQH Mandated Forms (also complete the Authorization and Release Form below):

Guardian Authorization and Release Form (for all CAQH mandated states)

 

District of Columbia

Indiana

Kansas

Kentucky

Maryland

Missouri

New Mexico

Ohio

Vermont

 

Standard Guardian Form:

All Other States

2. Disclosure of Ownership

If you participate in our Avesis (Government) Programs, you will need to complete a Disclosure of Ownership.  Please select the appropriate form for your state.

IA Disclosure of Ownership

KY Disclosure of Ownership

LA Disclosure of Ownership

NE Disclosure of Ownership

Standard Disclosure of Ownership (All Other States)

 

Please refer to your recredentialing letter for contact information should you have any questions or concerns.