To submit a credentialing request, please either send an email to Credentialing@betahg.com or fill out the below form. Please make sure to include a signed release with your request as well. Your Name* Phone Company Fax Address Email* Address 2 City Would you like someone to contact you directly? Yes No State How do you prefer to be reached? Email Phone Fax Mail Zip Please send us specific questions or comments in the space below:File UploadMax. file size: 50 MB.NameThis field is for validation purposes and should be left unchanged.