Central Verification Office Payment Form

Fill out the form below to pay your credentialing fees as provided by the Central Verification Office. If you have not received your final payment amount and been directed to this form to pay, please do not proceed.

Provider Information

Full Name *

CAQH ID *

Email *

Phone *

Payment Type *

Total Charges *

Payment Information

Name on Card *

Billing Address *

City *

State *

ZIP Code *

Credit Card Number *

Expiration Month *

Expiration Year *

Security Code *

The Security Code is located on the back of credit or debit cards and is typically a separate group of 3 digits to the right of the signature strip.

Premier Health protects your personal information. See our privacy policy.

Central Verification Office Payment Form

Thank you for supporting Premier Health

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Provider Information

Payment Information