Provider Billing Information

Instructions:

Please complete the below application and provide comments as appropriate.

All information is confidential.

Required fields are marked with an asterisk (*)

The information entered on this page can be saved to allow for completion at a later date. Incomplete requests will automatically delete from the system after 30 days of inactivity.

Provider/Group Name*

Type of Healthcare Provider*

Specialty (if physician)*

Primary Office Address*

Street Address Address Line 2 City State ZIP Code

Office Phone*

Primary Contact Name*

First Last

Primary Contact Phone Number*

Primary Contact E-Mail Address*

Enter Email Confirm Email

Facsimile Number

All additional office locations and phone numbers*

Location (Group Name and Address)	Phone Number

List of all Participating Practitioners currently participating and billing under the practice or group name*

Name (First & Last)	NPI

Billing Name*

Billing Contact Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Tax Identification Number*

NPI (Type II)*

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