New Provider Welcome Form - General Provider and Location Information

Please complete this form as it pertains to you. If you have any questions, please contact me directly at Sarah@palmettocredentialing.com.

Providers that are part of a group only need to fill out provider specific information.

Providers that own their group or practice need to fill out this form in its entirety.

Provider Name*

First NameLast Name

Provider Email Address*

example@example.com

Provider Phone (best number I can reach you on)*

Area CodePhone Number

Do you give me permission to reach you via text message? (credentialing related only)*

YesNo

What is your preferred form of communication?*

(Email, Phone, Text)

National Provider ID - Type One Individual*

Individual NPI

Please provide a Type Two NPI if you plan on receiving remittances under a company name.

Providers that are part of an established group or practice do not need to fill this out.

National Provider ID - Type Two Organization

Organization NPI

Tax ID - Organization Only (Company / LLC)

Tax ID

Name of Organization / Company as Reported to IRS

Who should checks be made out to?

Do you have a CAQH profile?*

YesNo

Please note that I will access your CAQH information to update your profile and to gather the sensitive information needed to complete your applications and updates. By entering your login information, you give me complete permission to access your profile.

CAQH LOGIN INFORMATION*

SERVICE LOCATION - PRIMARY

SERVICE LOCATION - SECONDARY (IF APPLICABLE)

MAILING ADDRESS - GENERAL CORRESPONDENCE

Where will remittances (EOBs and checks) be sent? (Please note it must be a physical address and not a PO Box)

Service Location - PrimaryService Location - SecondaryMailing Address

SERVICE LOCATION CONTACT INFORMATION

Is your service location ADA compliant?

YesNoUnknown

If you answered "yes", how is your service location ADA compliant? (signage, restrooms, parking lot etc.)

Is your practice location accessible by public transportation and if so, how?

Please list your hours at your practice location.

By signing below, I attest that the above information is accurate to the best of my knowledge.*