Client Set Up Information

Legal Name of Office
Client Set Up Information
Tax ID #
Group NPI
Supervising MD?

YesNo
Name of Supervising MD

First NameLast Name
NPI of Supervising MD
Providers:

(Please list the providers in your office who will be billing insurance.)
Provider 1

First NameLast Name
Specialty
Provider 1 NPI
Provider 2

First NameLast Name
Specialty
Provider 2 NPI
Provider 3

First NameLast Name
Specialty
Provider 3 NPI
Provider 4

First NameLast Name
Specialty
Provider 4 NPI
Provider 5

First NameLast Name
Specialty
Provider 5 NPI
Office address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address the insurance payments should be sent to:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you participate with Medicare?

YesNo
Group PTAN
DME PTAN (If applicable)
Please list the insurance companies you send claims to and note which ones you are in network with:
Please list any other websites where you receive EOBs (Navinet, Optum, etc):
Website
Website
Website
Website
Upload a copy of your offices fee/charge slip

Upload a File

Cancelof
Master Diagnosis Sheet

Upload a File

Cancelof
Should be Empty: