CAQH ID definition
CAQH ID. Group NPI: Tax ID: This authorization includes, but is not limited to, any and all information or documents related to licensure, federal or state-controlled substance certification, medical education and training, medical board certification or eligibility, participation in Medicare/Medicaid and other public assistance programs, malpractice coverage and criminal history, kept in either hardcopy or electronic form, related to my status as a credentialed physician with the applicable hospital(s). This authorization is effective now and will remain in effect until termination of my participation in CIN. I understand that I have a right to revoke in writing my consent to this disclosure at any time. I understand that I have a right to receive a copy of this authorization. Any copy of this document shall have the same authority as the original and may be substantial in its place. I HEREBY AUTHORIZE THE RELEASE OF MY CREDENTIALING INFORMATION AS PROVIDED ABOVE. Signed: Date: The Board has defined and adopted business criteria applicable to CIN membership eligibility. The criteria adopted relate to situations found to present likely conflicts of interest. All potential CIN members must complete the following questions prior to becoming a member.