EmailMe Form - BILLING PROVIDER DEMOGRAPHIC FORM

Date Time

MM / DD / YYYY

Owners Name

First Last

Clinic Name

HOW LONG AT AT THIS LOCATION

Business Entity Type

Sole Proprieter

Inc.

LLC

Tax ID *

Group NPI# (Type2)

SS# *

Medicare PTAN

Specialty

Clinic Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Payment Address (where do you want the insurance payments sent to?)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Office Phone

### - ### - ####

Cell Phone

### - ### - ####

Fax#

### - ### - ####

List all providers names and Individual NPI#s that we would do billing for:

Name

First Last

Individual NPI# (Type1)

Medicare PTAN

Name

First Last

Individual NPI# (Type1)

Medicare PTAN

Name

First Last

Individual NPI# (Type1)

Medicare PTAN

Name

First Last

Individual NPI# (Type1)

Medicare PTAN

Name

First Last

Individual NPI# (Type1)

Medicare PTAN

Email

Web Site

Names of Office Staff that can assist us with billing questions

Office Hours

Have you had any recent changes in your business. For example, Name change, Tax ID change or Address Change? If yes please explain below *

YES

NO

Any other information you would like us to know?