New Client Entity Form - Med Revenue Group

This secure form is designed to collect essential details about your business entity. Once submitted, you will be redirected to the practitioner credentialing application, which needs to be completed for each of your practitioners. For any inquiries or assistance, please feel free to contact our office at 866-866-7215

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: *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Primary Office Phone *

Primary Office Fax *

Primary Office Email

Primary Office Office Hours *

Hours

Minutes

Do you have any practice limitations *YesNo

Describe all Practice Limitations

Do you have Additional Office LocationsYesNo

Billing Address: (remit-to address)

Check Payable To: *

Billing Address and Contact same as Primary *YesNo

Correspondence Address:

Correspondence Address and Contact same as Primary *YesNo

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

Med Rec Same as Primary Office LocationYesNo

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

Does an organization own part of this entity *YesNo

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 apply5% or More Ownership InterestPartnerDirector/OfficerContracted Managing Employee

More Owners/Managers?

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

Do you utilize a billing company *YesNo

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 #

Select

Networks that you would like all your practitioners credentialed with:

HTML

Upon completing this form, you'll be directed to our Practitioner Credentialing Application to provide us with information about you, or the practitioners in your office.

You may upload required document copies at this time to help speed up your application process. these documents are needed to complete your credentialing file so that we have all information necessary to provide you with enrollment services.

Required Documents for your business entity include:1) IRS form CP575 or replacement letter 147C (verification of EIN) 2) Voided check that is pre-printed and matches EXACTLY (including suffixes such as LLC, Inc, etc) the business name on file with the IRS as shown on the CP575 or letter 147C. Or a letter from your bank verifying your bank account with the business name exactly as it appears on your EIN verification document. 3) Signed W-9 Form 4) CLIA Certificate (if performing laboratory tests in your clinic) 5) Business License (if applicable)

Upload fileUpload Entity Documents