Discovery Document

Business Information

* Indicates required field

Legal Business Name *

Primary Practice Address *

Line 1

Line 2

City

State

Zip Code

Country

Doing Business as *

Clinic Email Address *

Clinic Phone Number *

Clinic Fax Number *

Group NPI *

Group Tax ID *

CLIA Certification Number (if available) *

CLIA Expiration Date *

CLIA Effective Date *

List all Owners *

Business Establishment Date *

Office Manager/POC Name *

POC's Email Address *

Group's Specialty (Taxonomy) *

Billing Software (Currently in use) *

EMR (Currently in use) *

Group's PTAN *

Group TPI *

Additional Information *

Please provide copies of all following documents:

Completed & Signed W-9 Form
CLIA Certification (if available)
Certification of Filing
CP-575 (IRS Form)
Voided Check

Submit Group Info

Individual Provider Information

* Indicates required field

Provider Full Name *

Primary Specialty *

NPI Number *

Provider's DOB *

Provider's SSN *

Phone Number *

Email Address *

Driving License *

State License Number *

DEA Certification Number *

Medicare Number *

Medicaid Number *

CAQH ID *

Issued Date *

Effective Date *

Expiration Date *

Effective Date *

CAQH Username *

CAQH Password *

Place of Birth *

State of Birth *

Citizenship *

Hospital Privileges *

Practice Location(s) *

Will this provider only be acting as a Supervising Physician? *

Yes No

Please provide copies of all following documents:

State License
Driving License
DEA
Updated Resume
Professional Liability Sheet
All additional License/Certificates (if Any)

Submit Individual Provider's Info

Provider Discovery Document

Business Information

Individual Provider Information

Services

Company

Support