New Clinic Setup Form

Clinic Information
Below you will need to upload the following documents:
1. Your IRS CP575 letter which shows the legal entity name and Tax ID
2. A completed and signed W-9
3. 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.
Name*
First Last
Clinic Name*
Clinic Address*
Street Address Address Line 2 City State ZIP Code
Clinic Phone*
Clinic Fax
Clinic or Staff Email
Legal Entity Name*
The legal entity name of your business
Tax ID Number*
Do you have a Group NPI #?*
- Yes
- No
Group NPI Number
Group PTAN - Medicare Number
Is your clinic in network with any insurance companies?*
- Yes
- No
If yes, please list:
Do you currently use a clearinghouse?*
- Yes
- No
If yes, please list:
Upload These Documents
1. IRS CP575 Letter which shows the legal entity name and Tax ID.
2. W-9. Business name MUST be legal business name! For example, Acme LLC would need to be listed as Acme LLC, not Acme.
3. Voided check from your business account.
Drop files here or

Accepted file types: pdf, jpg, png.
Do you have any comments?
Name
This field is for validation purposes and should be left unchanged.

Clinic Information