Social Worker Credentialing Request

Credentialing is required for anyone who is at the masters or doctoral level in Social Work. When requesting credentialing for a new candidate, the requestor/supervisor/PI should complete the form below, which will be forwarded to Social Work department. Once received, the required registration documents and credentialing information will be sent to your candidate for completion. If you are requesting credentialing for multiple candidates, please submit a form for each one.

UPDATE TO PREVIOUS REQUEST SUBMISSION?: Did any requirements change for your candidate after last credentialing request submission? If yes click here to notify credentialing team with the updates instead of submitting a new request.

All fields marked with asterisk (*) are required.

Requestor's Information

Requestor Name

Requestor's Name cannot be empty

Requestor Email

Candidate's Information

First Name

Candidate's First Name cannot be empty

MiddleName

Last Name

Candidate's LastName cannot be empty

Additional Information

Entity:

NYS	RFMH
CU	Volunteer
NYP

Title

Title cannot be empty

Anticipated Start Date (for Research/Exempt)

PI/Faculty Supervisor

PI/Faculty Supervisor cannot be empty

PI/Faculty Supervisor Email

Is candidate exempt from credentialing?

Yes

Please select if candidate is exempt from credentialing

Will Candidate use HRO to submit documents?

Additional Notes/Comment