Trove New Client Intake Form

Trove MedLegal, LLC

New Client Intake Form
Todays Date:

MonthDayYear
Date
Name:

First NameLast Name
M.D.D.O.DC
Year Entered Practice (YYYY):
YesNoI want to be
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Preferred email:
example@example.com
Medical Specialty #1:
YesNoOther
Please Upload your Board Certification #1 here:

Required information for Registration Purposes
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Medical Specialty #2:
YesNoOther
Please Upload your Board Certification #2 here:

Required information for Registration Purposes
Cancelof
Primary Office Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
California Medical License Number:
California NPI Number:
Medical School Attended & Date of Degree (MM/YYYY):
Please provide detail in your CV
Residency Attended & from (MM/YYYY) to (MM/YYYY):
Please provide detail in your CV along with additional and/or other Residency information
Fellowship Attended & from (MM/YYYY) to (MM/YYYY):
Please provide detail in your CV
Airport Closest to you (i.e. LAX, BUR, SNA, etc.)?
Suffix or name please
Please sign here:
Please Upload your CV here:

Required information for QME Registration Purposes
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Bank Account Name:
Be very precise please
Bank Routing Number:
Be very precise please
Bank Account Number:
Be very precise please
Active Phone number connected to a Zelle Account:
If you use Zelle
Please Upload a complete copy of a voided check:

For the account you would like collections deposited to
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Please use this link to download and complete your W-9 form for accounting purposes, then upload your completed W-9 using the Drag and Drop file upload button below.

Blank W-9 Form
Please Upload your completed W-9 copy here:

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YesNoNot sure, it depends
NorCal - SF/OaklandNorCal - San Jose/StocktonNorCal - Sacramento/ModestoNorCal - East BaySoCal - San Diego/Escondido/Chula VistaSoCal - Orange County/Santa Ana/Costa MesaSoCal - LA County/Downey/Huntington Park/Gardena/Long BeachSoCal - LA County/Downtown LA/East LA/South Central LASoCal - LAX area, from Torrance to InglewoodSoCal - Inland Empire to San BernardinoCentral California - Tehachapi/BakersfieldCentral California - Palmdale/LancasterCentral California - Fresno

What is your availability to perform evaluations? This is not set in stone:

Rows	AM	PM	Lunch time	After clinic
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Number of hours you are willing to drive to perform an evaluation:
1, 2.5, 8?
What are your biggest fears for doing QME work? What do you hope to accomplish?
Who was the person that referred you?
If no one referred you please leave blank
What is the email address of a colleague, co-worker, or acquaintance that may be interested in QME work? If they sign up you will get a bonus!
example@example.com
What questions do you have for us?
For QME registration and form completion purposes, Trove needs a wet signature from you. Please use the link below to download the Signature Form, sign it, scan it or get a good clean digital photo, and send it back through the upload link below.

https://drive.google.com/file/d/1wE35HgC7Zbjgz65JLTP1KnTXwCCUY-f7/view?usp=drive_link
Please upload your completed signature form here:

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Please verify that you are human, and don't forget to press the SUBMIT button below. Thank you!*
Should be Empty:

Trove MedLegal, LLC