Care Network Link

Credentialing Fee Form

(* Denotes Required Fields)

Please provide the following information.
Organization: *
Name: *
Email: *
Phone Number: *
Amount of Fee
I am making a payment in the amount of: * Amount: $ 
Please note that credentialing fees paid as part of the application process to become a Care Network Link provider are non-refundable. 
Credit Card Payment Information
Amount: * $0.00
Card Type: *
Card Number: *
Name on Card: *
Verification #: * ?
Expiration Date: *
Billing Address: *
City, State, Zip: *

Refunds are not processed through this website. All refund requests need to be submitted in writing to AOASCC's Finance Department.