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Medical Billing Information from Providers
Information required from providers for medical billing services
Provider Name
Your answer
Provider "Doing Business As" name
Do you have a specific name for your practice?
Your answer
Tax ID
Your answer
Individual NPI
Your answer
Group NPI if LLC or PLLC corporation
Your answer
CAQH ID
Your answer
Date of Birth
MM
/
DD
/
YYYY
Social Security number
We will need the last 4 digits if you are not comfortable giving your full social security number
Your answer
License Number and effective dates
Your answer
Practice Address
Your answer
Mailing address if different from practice address
Your answer
Phone and Fax numbers
Your answer
Network Status
Check box if in-network
Insurance Companies that you are contracted with and are not listed above?
Your answer
Charges for services rendered *
90791, 90834, 90837, 90846, 90847, 90853, 90840, 90839, 90785
Your answer
Specialties (i.e. Anxiety, PTSD, Depression, etc.)
Your answer
Ages treated
Description of practice
Your answer
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