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Dastify Solutions

New Client Intake

Organization Information Data Intake Form

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

HIPAA Compliant
256-bit Encryption

Organization Information

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*