LPCC Setup Form Important Notes! At the end of this form, you will need to upload these documents: Liability Insurance Copy of your State License Board Certification (if you have it) Completed and signed W-9 form. Please list the legal business name on the form, not just the DBA. 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*Choose OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificYour 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 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 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 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: Liability Insurance Copy of your State License Board Certification (if you have it) Completed and signed W-9 form. Please list the legal business name on the form, not just the DBA. IRS CP575 Letter. This shows your business tax ID on it. Upload Files* Drop files here or Select files Max. file size: 256 MB. Δ