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.