New Chiropractor Setup Form – Advocate Insurance Billing

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 the following documents:
1. Your Current Chiropractic License (NOT a screenshot from a website!)
2. Your current Professional Liability Insurance Declarations
3. Your certificate from the National Board of Chiropractic Examiners (if you have one and are board certified)
If you do not have these available, you will need to wait to complete this form until you do.
First Name*
Last Name*
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*
Clinic Address*
Street Address Address Line 2 City State ZIP Code
What is the day you started working at this new clinic?*
(First date treating patients)
MM slash DD slash YYYY
Chiropractic License and Schooling
License Number*
Chiropractic, Medical, etc.
License State*
License Issue Date*
License Expiration Date*
Undergraduate School Name*
Undergraduate School Address*
Street Address Address Line 2 City State ZIP Code
Date Started*
Date Ended*
Name of Degree Earned*
Chiropractic School Name*
Chiropractic School Address*
Street Address Address Line 2 City State ZIP Code
Date Started*
Date Ended*
NPI and Accounts
Do you have an individual NPI #?*
- Yes
- No
Your Individual NPI #
Your Individual Medicare PTAN - Medicare #
Do you have a CAQH account set up yet?*
If not, we will set up one for you and will provide you with the information.
- Yes
- No
If yes, please list username and password:
Do you have an Identity & Access/PECOS account set up yet?*
- Yes
- No
If yes, please list your 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:
Employment History

We need your employment history for credentialing with various insurance companies. Please be as detailed as possible to save us time asking you for this info later.

Please list employment history for the past 10 years. Start with your most recent or current employer and work back from there.
Are there any gaps in your employment record?*
- Yes
- No
Explain any Gaps in Employment Record
List start date, end date, and reason for unemployment.
Company Name*
Company Address*
Street Address Address Line 2 City State ZIP Code
Company Phone*
Contact Email*
We need a contact email for someone at this company.
Start Date*
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Do you have another employment record to add?*
- Yes
- No
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Company Phone
Contact Email
We need a contact email for someone at this company.
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Do you have another employment record to add?
- Yes
- No
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Company Phone
Contact Email
We need a contact email for someone at this company.
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Do you have another employment record to add?
- Yes
- No
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Company Phone
Contact Email
We need a contact email for someone at this company.
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Do you have another employment record to add?
- Yes
- No
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Company Phone
Contact Email
We need a contact email for someone at this company.
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Do you have another employment record to add?
- Yes
- No
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Company Phone
Contact Email
We need a contact email for someone at this company.
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Do you have another employment record to add?
- Yes
- No
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Company Phone
Contact Email
We need a contact email for someone at this company.
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Do you have another employment record to add?
- Yes
- No
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Company Phone
Contact Email
We need a contact email for someone at this company.
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Professional References
Please list three professional references.
First Person Name*
First Last
What is this person's degree or profession?*
For example, chiropractor
First Person Phone*
First Person Email*
First Person Address*
Street Address Address Line 2 City State ZIP Code
Second Person Name*
First Last
What is this person's degree or profession?*
For example, chiropractor
Second Person Phone*
Second Person Email*
Second Person Address*
Street Address Address Line 2 City State ZIP Code
Third Person Name*
First Last
What is this person's degree or profession?*
For example, chiropractor
Third Person Phone*
Third Person Email*
Third Person Address*
Street Address Address Line 2 City State ZIP Code
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 the following:
1. Your Current Chiropractic License (NOT a screenshot from a website!)
2. Your current Professional Liability Insurance Declarations
3. Your certificate from the National Board of Chiropractic Examiners (if you have one and are board certified)
Upload Files*
Drop files here or

Max. file size: 256 MB.

Welcome to Advocate Insurance Billing

Doctor's Information*

Your Clinic Information

Chiropractic License and Schooling

NPI and Accounts

Employment History

Professional References

NOTICE!!! Upload the following: