New BCBA Setup Form – Advocate Insurance Billing

BCBA's Information

At the end of this form, you will need to upload these documents:

Your Liability Insurance
Your State License
Your BACB Board Certificate
Your CPR/BLS Certificate

If you do not yet have all the documents, you will need to wait on completing this form until you do.

First Name*

Last Name*

Your Email*

Your Cell Phone #*

Your Date of Birth*

City of Birth*

State of Birth*

Your Social Security Number*

Your Home Address*

Street Address Address Line 2 City State ZIP Code

Your Individual NPI #*

Your Behavior Analyst License #*

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.

What insurance companies (if any) have you been enrolled in in the past or are currently enrolled in?

Work History*

This is required for credentialing with many insurance companies! Please include business name, month/year started and month/year ended (month is required, not just the year). Must also explain any gaps in employment history!

Name of Professional Reference 1*

Please provide a professional reference of yours. This does not mean a personal friend or family member.

First Last

What is their profession?*

For example, Applied Behavioral Analyst, Chiropractor, etc.

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name of Professional Reference 2*

Please provide a professional reference of yours. This does not mean a personal friend or family member.

First Last

What is their profession?*

For example, Applied Behavioral Analyst, Chiropractor, etc.

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Professional Reference 3*

Please provide a professional reference of yours. This does not mean a personal friend or family member.

First Last

What is their profession?*

For example, Applied Behavioral Analyst, Chiropractor, etc.

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Clinic Information

Clinic Name (Legal Business Name)*

What is the day you started working/will start at this new clinic?*

(First date treating patients)

Upload the following documents:

Your Liability Insurance
Your State License
Your BACB Board Certificate
Your CPR/BLS Certificate

Upload Files*

Drop files here or

Max. file size: 256 MB.