Doctor Setup Form – Advocate Insurance Billing

Doctor's Information*

*Below you will need to upload your current Chiropractic License (NOT a screenshot from a website!). If you do not have this available, you will need to wait to complete this form until you do.

Name*

First Last

Your Email*

Your Personal Phone*

Your Date of Birth*

Your Social Security Number*

Your Home Address*

Street Address Address Line 2 City State ZIP Code

Your Birth City*

Your Birth State*

Your Clinic Information

Clinic Name*

What is the day you started working at this new clinic?*

(First date treating patients)

Chiropractic License

License Number*

Chiropractic, Medical, etc.

License State*

License Issue Date*

License Expiration Date*

What Chiropractic School did you go to?*

What year did you graduate?*

NPI and Accounts

Do you have an individual NPI #?*

Yes
No

Your Individual NPI #

Do you have an Identity & Access/PECOS account set up yet?*

Note: If you have an NPI then you have an Identity & Access account! https://nppes.cms.hhs.gov/IAWeb/warning.do

Yes
No

If yes, please list your username and password.

Your Individual Medicare PTAN - Medicare #

Do you have a CAQH account?*

Yes
No

If yes, please list username and password:

Are you enrolled in Medicaid?*

Yes
No

Are you In Network with any other insurance companies?*

Yes
No

If yes, please list:

Has a final adverse legal action ever been imposed against you under any current or former name or business entity?*

What does this mean?

Yes
No

NOTICE!!! Upload your current Chiropractic License (NOT a screenshot from a website!)

Upload Files*

Drop files here or

Max. file size: 256 MB.

Welcome to Advocate Insurance Billing

Doctor's Information*

Your Clinic Information

Chiropractic License

NPI and Accounts

NOTICE!!! Upload your current Chiropractic License (NOT a screenshot from a website!)