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v3 © 03-2006 New Client - Healthcare

PROVIDERS THAT USE THIS APPLICATION AND SUBMIT THEIR PATIENT BILLING INFORMATION OVER THE WEB HAVE ALL ORIGINATION FEES WAIVED.

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NEW CLIENT IMP FORM

THIS IS A SECURE DOCUMENT

128 BIT ENCRYPTED FOR COMPLETE SAFETY

THIS APPLICATION IS USED FOR NEW HEALTH CARE PROVIDER CLIENT PROCESSING ONLY.

* minimum required information

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Account Information
* Your Name

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* Practice Name
Address Line 1
Address Line 2
City
State
Zip
* Business Phone
Fax Phone No.
* E-Mail

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Provider Information

Medicare No.

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Medicaid No.

Other Provider Numbers

Participate w / Medicare

YES NO

Tax I.D. No.

Billing Signature Name / Title
  

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Operations Information

Provider Contact Names

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* Office Hours

Special Instructions

for Your Account

Do You Have Web Site ?

Have a Site Now ( it's address )

Want to Build Don't Want One

Other Comments / Notes

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