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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