Provider Information: Provide information about your practice and your legal entity. It is very important that you provide complete information about your legal entity so that we set up your facility correctly in our system in order to properly populate your enrollment or privilege applications.
This is the primary email contact that we will use for while providing you services
Please provide days and hours of operations
Medical Records Storage Location: (address where patient records are stored)
Organizations with Ownership Interest and/or Managing Control of the Supplier:
Billing Agency: (complete if you use an external billing agency)
Electronic Funds Transfer (EFT) Information: (**REQUIRED FOR MEDICARE ENROLLMENT**)
Upon completing this form, you'll be directed to our Practitioner Credentialing Application to provide us with information about you, or the practitioners in your office.
You may upload required document copies at this time to help speed up your application process. these documents are needed to complete your credentialing file so that we have all information necessary to provide you with enrollment services.
Required Documents for your business entity include: 1) IRS form CP575 or replacement letter 147C (verification of EIN) 2) Voided check that is pre-printed and matches EXACTLY (including suffixes such as LLC, Inc, etc) the business name on file with the IRS as shown on the CP575 or letter 147C. Or a letter from your bank verifying your bank account with the business name exactly as it appears on your EIN verification document. 3) Signed W-9 Form 4) CLIA Certificate (if performing laboratory tests in your clinic) 5) Business License (if applicable)
