New Clinic Setup Form

"*" 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!

*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.

DBA (Doing Business As)?

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

Tax ID Number*

Corporate Structure*

What type of entity is your clinic?

Sole proprietor or single member/owner LLC (only one owner)

Multiple member/owner LLC

C Corporation

S Corporation

Partnership

Trust/estate

Tax Classification of multiple member/owner LLC*

C Corporation

S Corporation

Partnership

Name of Owner of Clinic/Business*

First Last

Social Security Number of Owner*

Date of Birth*

NPI of Owner (if a healthcare provider)

Country of Birth*

State / Province / Region Country

You will need to list ALL OWNERS of this clinic whether they are other businesses and/or individuals. This is required by Medicare.

Is the first owner another business entity or is it an individual?*

Individual

Business/Entity

Name of Owner*

First Last

Social Security Number of Owner*

Date of Birth*

NPI of Owner (if a healthcare provider)

Country of Birth*

State / Province / Region Country

Percent of Ownership*

Legal Business Name*

"Doing Business As" Name (if applicable)

Tax Identification Number (Also called an EIN/Employer Identification Number)*

Group NPI of Business (If applicable)

Business Address*

Street Address Address Line 2 City State ZIP Code

Percent of Ownership*

Is the second owner another business entity or is it an individual?*

Individual

Business/Entity

There isn't another owner

Name of Owner*

First Last

Social Security Number of Owner*

Date of Birth*

NPI of Owner (if a healthcare provider)

Country of Birth*

State / Province / Region Country

Percent of Ownership*

Legal Business Name*

"Doing Business As" Name (if applicable)

Tax Identification Number (Also called an EIN/Employer Identification Number)*

Group NPI of Business (If applicable)

Business Address*

Street Address Address Line 2 City State ZIP Code

Percent of Ownership*

Is the third owner another business entity or is it an individual?*

Individual

Business/Entity

There isn't another owner

Name of Owner*

First Last

Social Security Number of Owner*

Date of Birth*

NPI of Owner (if a healthcare provider)

Country of Birth*

State / Province / Region Country

Percent of Ownership*

Legal Business Name*

"Doing Business As" Name (if applicable)

Tax Identification Number (Also called an EIN/Employer Identification Number)*

Group NPI of Business (If applicable)

Business Address*

Street Address Address Line 2 City State ZIP Code

Percent of Ownership*

Is the fourth owner another business entity or is it an individual?*

Individual

Business/Entity

There isn't another owner

Name of Owner*

First Last

Social Security Number of Owner*

Date of Birth*

NPI of Owner (if a healthcare provider)

Country of Birth*

State / Province / Region Country

Percent of Ownership*

Legal Business Name*

"Doing Business As" Name (if applicable)

Tax Identification Number (Also called an EIN/Employer Identification Number)*

Group NPI of Business (If applicable)

Business Address*

Street Address Address Line 2 City State ZIP Code

Percent of Ownership*

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

Please answer this truthfully. If you don't know, please talk with the owners to discuss. Please see "Final Adverse Legal Actions That Must be Reported".

Yes

If yes, please describe.

Clinic Address*

THIS MUST BE THE CLINIC/PRACTICE ADDRESS! NOT THE MAIN OFFICE/HEADQUARTERS, ETC.

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

Group PTAN - Medicare Number

Is your clinic in network with any insurance companies?*

Yes

Not sure

If yes, please list:

Do you currently use a clearinghouse?*

Yes

Not sure

If yes, please list:

Clinic's Bank Name*

For example, Chase, Wells Fargo, etc. We need this to set up EFT with Medicare.

Bank Address*

We need this to set up EFT with Medicare.

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 Medicare or other insurance companies.*

Yes

Phone

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