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

* Indicates required field

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)

SUPPORTING DOCUMENTS (INDIVIDUAL PROVIDER)

INDIVIDUAL PROVIDER CONSENT FORM

Medical billing discovery

Services

Company

Support