New Clinic Setup Form – Short – Advocate Insurance Billing

New Clinic Setup Form – Short

"*" indicates required fields

Clinic Information

Below you will need to upload the following documents:

Your IRS CP575 letter which shows the legal entity name and Tax ID*
A voided check of your clinic's business account.* MUST have the business name and address printed on the check! This is needed because most insurance companies require an electronic payment method to pay you for your services to patients.

*If you do not have these documents you will need to wait to complete this form until you have obtained these documents.

Your Name*

First Last

LEGAL Name of Clinic*

Do not put a DBA (Doing Business As) name. Must be the FULL LEGAL name of the clinic. You will find this on the state formation documents or on the IRS letter with your Tax ID/EIN number.

Tax ID Number*

DBA (Doing Business As)?

Does clinic have a DBA name? If so, please list.

Name of Owner of Clinic/Business*

First Last

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

Please answer this truthfully. Please see "Final Adverse Legal Actions That Must be Reported".

Yes

If yes, please describe.

Clinic Address*

Street Address Address Line 2 City State ZIP Code

Clinic Phone*

Clinic Fax

Clinic or Staff Email

Do you have a Group NPI #?*

Yes

Group NPI Number

Is your clinic in network with any insurance companies?*

Yes

If yes, please list:

Do you currently use a clearinghouse?*

Yes

If yes, please list:

Clinic's Bank Name*

For example, Chase, Wells Fargo, etc.

Bank Address*

Street Address Address Line 2 City State ZIP Code

Upload These Documents*

1. IRS CP575 Letter which shows the legal entity name and Tax ID.
2. Voided check from your business account.

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 256 MB.

Do you have any additional comments?

I attest that the information I am submitting is true and complete to the best of my knowledge. I understand that this information will be used for setting up accounts and insurance credentialing. I understand that submitting false or incomplete information may have negative consequences including, but not limited to, being terminated/unenrolled from insurance companies.*

Yes

Name

This field is for validation purposes and should be left unchanged.