Wellness Way Clinic Owner

We are excited to have you as an owner of a new Wellness Way Clinic!

Please take the time to provide us with this information, so that we can get the clinic enrolled in the Insurance Companies that it is seeking to join (e.g. Medicare, Medicaid if applicable, BCBS if applicable). These insurance companies need the following information from each owner of this entity to be able to process the insurance enrollments. This information will be secure. Thank you for your help.

Your Full Legal Name*
First Middle Last
Your Social Security Number*
Your Date of Birth*
Your Home Address*
Street Address Address Line 2 City State ZIP Code
County of your Home Address*
Your Birth State*
Your Personal Phone Number*
Your Email Address*
Which new Wellness Way Clinic are you part owner of?*
Percentage of Ownership in this new Wellness Way Clinic*
Comments
This field is for validation purposes and should be left unchanged.