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 Clinic Name*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 FaxClinic or Staff Email Legal Entity Name*The legal entity name of your businessTax ID Number*Do you have a Group NPI #?*YesNoGroup NPI NumberGroup PTAN - Medicare NumberIs your clinic in network with any insurance companies?*YesNoIf yes, please list:Do you currently use a clearinghouse?*YesNoIf 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 Accepted file types: pdf, jpg, png. Do you have any comments?NameThis field is for validation purposes and should be left unchanged.