Do not use a mobile device to complete this form as it may not work correctly. Please use a desktop computer, laptop, or tablet. Welcome to Advocate Insurance Billing Please take the time to provide this information so that we can get you set up for billing for the services you provide. 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Birth City* Your Birth State* Your Clinic InformationClinic Name* What is the day you started working at this new clinic?*(First date treating patients) MM slash DD slash YYYY Chiropractic License License Number*Chiropractic, Medical, etc. License State*Choose OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense Issue Date* License Expiration Date* What Chiropractic School did you go to?* What year did you graduate?* NPI and AccountsDo 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 Select files Max. file size: 256 MB. Δ