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 BCBA License
Your CPR 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 BCBA License
Your CPR Certificate

Upload Files*

Drop files here or

Max. file size: 256 MB.