2024-Soteria-Annual-Provider-Info-Update-Form-01-03-2024

SOTERIA HEALTHCARE NETWORK: Annual Provider Information Update Form

OFFICE INSTRUCTIONS: DUE NO LATER THAN MARCH 1st (of each year)

Please submit this completed document online. You may also, print it and fax back to (770) 455-4120 or email it back to Soteria at claims@soteriahealthcare.com.

This updated form and practice information is required annually by Soteria Healthcare Network.

Any questions/comments, please call 770-455-8190 ext 135.
Full Name (Chiropractic Provider)*

First NameLast Name
Practice Name As it appears on W-9*
Office Tel*
Fax*
TIN*
NPI Indiv*
Medicare Indiv*
Medicaid Indiv*
Professional Insurance Carrier*
Exp Date*

MonthDayYear
Date
Per Claim Limit of Liability $*
Aggregate Amount $*
Business Liability Insurance Carrier*
Exp Date*

MonthDayYear
Date
Current Practice Address
Street Address*
City State Zip*
County*
Office Hours
Monday Hours*
Tuesday Hours*
Wednesday Hours*
Thursday Hours*
Friday Hours*
Saturday Hours*
Sunday Hours*
Additional Comments About Office Hours*
Primary Email Address*
example@example.com
Web Site Address*
Languages Spoken*
Type of Practice: Group or Solo*
If Group Practice, please list the names first and last of all of the other providers practicing at this location*
Office Information
Total Number of Exam Rooms*
Total Number of Exam Tables*
Total Number of CAs Employed*
Massage Therapy Offered At Practice (YES or NO)*
Do You Accept New Patients At This Location?*
Do You Have Any Age Restrictions?*
Age Restrictions (If yes, please describe)
On-Site X-Ray (YES or NO)*
Make/Model of X-Ray Machine:*
Date of Last State Certification (X-Ray Machine)*
This Form Was Completed By First Last Name Printed*
Todays Date*

MonthDayYear
Date
Do you also practice out of other locations? (YES or NO)*
SECONDARY PRACTICE LOCATION

Other Practice Address You See/Treat Patients At Include:
Second Practice Location Address

Street Address

Street Address Line 2

City State ZipState / Province

Postal / Zip Code
Second Practice Location Office Tel
Second Practice Location Fax
Third Practice Address You See/Treat Patients At Include:
Third Practice Location Address

Street Address

Street Address Line 2

City State ZipState / Province

Postal / Zip Code
Third Practice Location Office Tel
Third Practice Location Fax
Fourth Practice Address You See/Treat Patients At Include:
Fourth Practice Address

Street Address

Street Address Line 2

City State ZipState / Province

Postal / Zip Code
Fourth Practice Office Tel
Fourth Practice Office Fax
DO NOT FORGET "IF YOUR ADDRESS HAS CHANGED IN THE PAST YEAR
Please be sure to submit your updated W-9 "REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND

This W-9 Form can be found and submitted in two ways:

1. Submit online by visiting www.SoteriaHealthcare.com/downloads; or 2. Visit https://www.irs.gov/forms-pubs/about-form-w-9and fax your updated W-9 back to Soteria Healthcare at fax # 770-455-4120.

Questions, please call 770-455-8190. Thank you!

LAST UPDATED: JANUARY 25, 2024 I Tel. 770-455-8190 I Fax 770-455-4120
Should be Empty:

Current Practice Address

Office Hours

Office Information

DO NOT FORGET "IF YOUR ADDRESS HAS CHANGED IN THE PAST YEAR