New Clinic Setup Form Clinic InformationBelow you will need to upload the following documents: Your IRS CP575 letter which shows the legal entity name and Tax ID A completed and signed W-9 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 LEGAL Name of Clinic* DBA (Doing Business As)?Does clinic have a DBA name? If so, please list. Clinic Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Documents1. 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 Select files Accepted file types: pdf, jpg, png, Max. file size: 256 MB. Do you have any comments?CommentsThis field is for validation purposes and should be left unchanged.
