Provider Signup Information Form

Provider Signup Information Form

Please complete all sections to ensure accurate setup for medical billing and insurance claims. Information will be used as entered.
Provider Information
Role
Provider Name (no nicknames)
Credentials
License Number
Date of Birth

MonthDayYear
Date
Billing Preference (no birth center)
Use business name when setting up my account
Billing Preference (have a birth center)
Billing Preference (professional and facility services)
Individual Tax Identification Number
Individual Tax Identification Type
Business Tax Identification Number (EIN)
Individual NPI #
Group/Business NPI #
Do you have a CLIA waiver?
CLIA waiver number
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Physical Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Best phone # to reach you
Please enter a valid phone number.Format: (000) 000-0000.
Alternate phone #
Please enter a valid phone number.Format: (000) 000-0000.
Fax number
Please enter a valid phone number.Format: (000) 000-0000.
Do we need to call before faxing?
Email address
example@example.com
Website
Business Name (if applicable)
Is this a Birthing Center?
Birthing Center License Number
Type of Practice
Type of Practice - Notes
Have you billed insurance companies before?
BC/BS PIN
Medicaid PIN
Other PIN
Major companies billed previously

Other
Major companies billed previously - Other
Are you registered for any online claim access information?
If yes, which companies?
Do any insurance companies have you in their system with outdated demographics information?
Send Previous Demographic Information Form to (fax)
Please enter a valid phone number.Format: (000) 000-0000.
Send Previous Demographic Information Form to (email)
example@example.com
Average number of births per year (insurance)
Are you willing to have us set you up for electronic EOBs (ERAs)?
Partner/Employee Information
Partner/Employee Role
Partner/Employee Provider Name (no nicknames)
Partner/Employee Credentials
Partner/Employee License Number
Partner/Employee Date of Birth

MonthDayYear
Date
Best phone # to reach partner
Please enter a valid phone number.Format: (000) 000-0000.
Alternate phone # for partner
Please enter a valid phone number.Format: (000) 000-0000.
Partner Fax number
Please enter a valid phone number.Format: (000) 000-0000.
Do we need to call partner before faxing?
Partner Email address
example@example.com
Partner Website
Partner Individual NPI #
Does partner have a CLIA waiver?
Partner CLIA waiver number
Has partner billed insurance before?
Partner BC/BS PIN
Partner Medicaid PIN
Partner Other PIN
Partner major companies billed previously

Other
Do any insurance companies have partner in their system with outdated demographics information?
Additional claims access - Are there others you would like to allow viewing access?
Additional claims access - Names
Have you been informed about the BWMB Client Billing Program (cash pay)?
Are you interested in enrolling in our Client Billing Program?
Would you like information about the Client Billing Program?
How would you like BWMB to send your invoices to you?
Is your computer a Mac?
Names & phone #s of your associates who will be in contact with us
How did you hear about us?
Additional information you would like us to know
Signature 1
Date 1

MonthDayYear
Date
Print Name 1
Signature 2
Date 2

MonthDayYear
Date
Print Name 2
Should be Empty:

Provider Signup Information Form

Provider Information

Partner/Employee Information