Instructions for completing Request for Change to Add an Already Credentialed Clinician

Please read all instructions below to ensure that you have all required information available before proceeding to complete a change request form. 
* Effective immediately, all email notifications received from Cardinal Innovations regarding this request may be sent via a secure email message. The first time that you receive a secure message you will also receive a password notification message containing initial login information. Please follow the instructions contained within the password notification message in order to proceed. The password created will be needed for subsequent email messages you receive regarding this request.

Only authorized representatives of the provider should complete this form.


  1. Provider is responsible for ensuring that it has all necessary service codes in its contract for the license type of the clinician it is adding, otherwise claims will deny.
  2. If the Clinician is not currently enrolled or affiliated with each Agency/Practice site in NC Tracks, please visit the NC Tracks Provider Portal to submit a new NCTracks enrollment application or a Manage Change Request (MCR), if already enrolled to affiliate the credentialed clinician to the desired site(s).
  3. You may request an “Effective Date of Clinician Association" up to 90 days prior to the actual submission date of the form in order to coincide with contractual billing days and to allow time for the submission of any NCTracks processing records.
  4. Please list the Agency/Practice name as indicated on the contract with Cardinal Innovations Healthcare Solutions. The Agency/Practice ID Number and any Site Numbers may be obtained by logging into Provider Direct and clicking “Admin" and “Provider Management”.
  5. Please list the name of clinician as listed on the clinician's licensure or certification.
  6. Please make sure that a valid Clinician's NPI # is included.
  7. In the section for "Identification of Provider Sites that Clinician will be associated with, you may list the sites by site ID number and other particulars in the form where service delivery will occur


Once the form is submitted, you will have 36 hours to fax the following documents to 704-939-7503:

  • Licensure or Certification,
  • Certificate of Professional Liability insurance for Clinician
  • NCTracks documentation as described above

When faxing the documentation please include the Reference Number in the Fax Cover Page; the Reference Number will be provided in the confirmation email response you will receive upon submittal of this form.

Failure to provide documents within the required timeframe will result in form not being processed.


If you have the information listed above, please click 'Proceed' to complete the form.

If you do not have all the information listed above, please return to this site at a later time.   
*Please note - If you are using a or email address, please add to your safe senders list.  Please also check your junk folder for the confirmation email.