LPCC Setup Form

Important Notes!
At the end of this form, you will need to upload these documents:
1. Liability Insurance
2. Copy of your State License
3. Board Certification (if you have it)
4. Completed and signed W-9 form. Please list the legal business name on the form, not just the DBA.
5. IRS CP575 Letter. This shows your business tax ID on it.
If you do not yet have all the documents, you will need to wait on completing this form until you do.
Name*
First Last
Your Email*
Your Phone*
Sex*
- Male
- Female
Your Date of Birth*
City of Birth*
State of Birth*
Your Social Security Number*
Your Home Address*
Street Address Address Line 2 City State ZIP Code
Your Individual NPI #*
Your License #*
Your Taxonomy Code
Do you have a CAQH account set up yet?*
- Yes
- No
If yes, please list username and password:
If you do have a CAQH account, the information must be correct and up-to-date.
Clinic Name (Legal Business Name)*
Clinic Tax ID*
Clinic Phone #*
Clinic Email
Clinic Address*
Street Address Address Line 2 City State ZIP Code
What is the day you started working/will start at this new clinic?*
(First date treating patients)
MM slash DD slash YYYY
Upload the following documents:
1. Liability Insurance
2. Copy of your State License
3. Board Certification (if you have it)
4. Completed and signed W-9 form. Please list the legal business name on the form, not just the DBA.
5. IRS CP575 Letter. This shows your business tax ID on it.
Upload Files*
Drop files here or

Max. file size: 256 MB.