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Provider Discovery Document

Through this form, you help us get an idea about yourself, your group,  what kind of payers you’d like to be linked with.

    Business Information

    Full Legal Business Name
    Enter Full DBA
    Email for General Correspondence
    Phone for General Correspondence
    Fax for General Correspondence
    Enter Group's National Provider Identifier
    Enter Group's Tax Identification Number
    Enter Clinical Laboratory Improvement Amendments Certification Number
    Enter full name of all Owner(s)
    Enter the full mm/dd/yyyy.
    Enter full name of POC/Manager
    POC's Email address for correspondence
    Enter Group's Taxonomy Specifying Specialty
    Enter the name of Billing software currently in use (if any)
    Enter the name of EMR which is in use of the Clinic (if any)
    Enter Group's Medicare Number
    Enter Group's TPI Number
    Enter all additional information/request/instructions here

    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

    Enter Full Name as (First, Middle, Last Name + Degree)
    Enter Provider's Primary Specialty With Taxonomy Code
    Enter Provider's National Provider Identifier (if available)
    Enter Provider's Date of Birth
    Enter Provider's Social Security Number
    Enter Phone Number which can be used for General Correspondence
    Enter Email Address which can be used for General Correspondence
    Enter State's Driving License Number
    Enter Provider's Active State License Number
    Enter Provider's Active DEA Certification Number
    Enter Individual Provider's Medicare Number
    Enter Individual Provider's Medicaid Number
    Enter CAQH ID (if available)
    Enter Issue Date of Driving License
    Enter State License's Effective Date
    Enter DEA Certification Effective Date
    Enter Expiration Date of Driving License
    Enter State License's Expiration Date
    Enter DEA's Expiration Date
    Enter Medicare's Effective Date
    Enter Medicaid's Effective Date
    Enter CAQH Username
    Enter CAQH Password
    Enter Provider's Place of Birth
    Enter Provider's State of Birth
    Enter Provider's Citizenship
    Enter Provider's Hospital Privileges (if available) along with the address and type of Privileges
    Enter all Locations Where Provider is (currently/going to) Provider Services

    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

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  • Home
  • Features
    • Why Choose Us?
    • Consulting
    • Security
    • About
  • Services
    • Provider Credentialing
    • Medical Billing Services
    • Denial Management
  • Request a Quote
  • Blog
  • Contact
  • WIKI
  • Multimedia
  • Login