Billing Discovery Information

PURPOSE: The aim of this information is to ascertain the specifics of your medical practice, and to understand the minute details of your facility before we begin working on the credentialing, billing and collection processes.

Business information

Legal Business Name *

Name of Principle Owner *

Primary Correspondence Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone *

Fax *

Email *

Specialty *

CLIA *

Facility NPI *

Federal Tax ID *

Business Establishment Date *

Comment *

Submit

practice location information

individual provider information

ownership information

insurance information

supporting documents (Group)

Provider Name / Group Name *

Email *

W-9 *

Max file size: 20MB

Certificate of Filing (Office of the Secretary of State) *

Max file size: 20MB

CP-575 (Department of the Treasury, Internal Revenue Service) *

Max file size: 20MB

Clinical Lab Improvement Amendment – CLIA Certificate *

Max file size: 20MB

Voided Check *

Max file size: 20MB

Submit

SUPPORTING DOCUMENTS (INDIVIDUAL PROVIDER)

Provider Name / Group Name *

Email *

Copy of State Medical Licenses *

Max file size: 20MB

Copy of Driver’s License *

Max file size: 20MB

Copy of DEA *

Max file size: 20MB

Copy of DPS *

Max file size: 20MB

Updated Resume *

Max file size: 20MB

Copy of Professional Liability Insurance *

Max file size: 20MB

Copy of RN & APRN Licenses (if provider is a Nurse Practitioner) *

Max file size: 20MB

Submit

INDIVIDUAL PROVIDER CONSENT FORM

Medical billing discovery

Services

Company

Support