New Client Entity Form

Practice Name

Person Completing This Form

Contact Phone

Contact Email

Provider Information: Please provide detailed information about your practice and legal entity. Accurate and complete details are crucial for us to properly set up your facility in our system and ensure that your enrollment or privilege applications are correctly populated.

Type of Supplier

Full Business Legal Name

dba

Tax ID #

Type of organization (Corp, PC, LLC, etc)

Incorporation date

Incorporation State

Type 2 NPI

NPI Username

NPI Password

CLIA Certificate#

Group Medicare#

Group Medicaid#

Medicare DME#

Primary Office Location:

Primary Office Address:

Primary Office Address

Primary Office City, ST Zip

Primary Office County

Primary Office Phone

Primary Office Fax

Primary Office Email

Primary Office Office Hours

Do you have any practice limitations

Yes

Describe all Practice Limitations

Do you have Additional Office Locations

Yes

Billing Address: (remit-to address)

Check Payable To:

Billing Address and Contact same as Primary

Yes

Correspondence Address:

Correspondence Address and Contact same as Primary

Yes

Medical Records Storage Location: (address where patient records are stored

Med Rec Same as Primary Office Location

Yes

Organizations with Ownership Interest and/or Managing Control of the Supplier:

Does an organization own part of this entity

Yes

Individuals with Ownership Interest and Managing Control of the Supplier:

List all owners of your business entity. The total ownership must equal 100%, upload spreadsheet or MS Word document if you need to report more owners than allowed on this form.

Full Name

DOB

SSN

NPI

Medicare #

% Ownership

Check all that apply

5% or More Ownership Interest

Partner

Director/Officer

Contracted Managing Employee

More Owners/Managers?

Billing Agency: (complete if you use an external billing agency)

Do you utilize a billing company

Yes

Electronic Funds Transfer (EFT) Information: (**REQUIRED FOR MEDICARE ENROLLMENT**)

Bank Name

City, ST

Bank Phone #

Bank Contact Person

Name on Account

Bank Routing #

Bank Account #

Type of account

Networks that you would like all your practitioners credentialed with: