New Client Intake

Organization Information Data Intake Form

Complete all sections below to begin the credentialing process. Your information is encrypted and stored securely.

Legal business details and contact information

Legal Business Name

Doing Business As (DBA) Name

Organization NPI (Type 2)

Tax ID Number (EIN)

Physical Practice Address

Mailing / Correspondence Address *

Practice Phone Number

Organization Email

Business owner details and ownership structure

Owner Name

Owner SSN

Owner Date of Birth

Percentage of Ownership

PECOS (Medicare) Login

User ID

Password

Medicaid State Portal Login

User ID

Password

Availity Essentials Login

User ID

Password

UnitedHealthcare (UHC) / Optum ID

User ID

Password

Upload all required documentation

Please Upload in PDF, Jpeg, PNG Format Only.

IRS CP-575 or 147C Letter

W-9 Form

Certificate of Liability Insurance (COI)

Business License

Company Letterhead

Current CV / Resume

Professional State License

DEA Certificate

Board Certification

Driver's License