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Medical Billing Information from Providers
Information required from providers for medical billing services
Provider "Doing Business As" name
Do you have a specific name for your practice?
Group NPI if LLC or PLLC corporation
Date of Birth
Social Security number
We will need the last 4 digits if you are not comfortable giving your full social security number
License Number and effective dates
Mailing address if different from practice address
Phone and Fax numbers
Check box if in-network
Anthem BCBS PPO
Anthem HealthKeepers Plus
Optima Behavioral Health
Medicare (We will need PTAN)
Insurance Companies that you are contracted with and are not listed above?
Charges for services rendered
90791, 90834, 90837, 90846, 90847, 90853, 90840, 90839, 90785
Specialties (i.e. Anxiety, PTSD, Depression, etc.)
Infant-5 years old
Description of practice
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