Insure One Accounting & Insurance Solutions / The Tax Ladies - Insure One- Provider Enrollment General Request

Insure One- Provider Enrollment General Request

What is the name of the Provider (if individual), Provider Group, or Facility name?*

Primary Email*

First Name*

Last Name*

Title*

Website*

Address Line 1*

Address Line 2*

City*

State / Province*

ZIP / Postal Code*

How is your facility/provider registered with the state or how will you operate your practice if you are unregistered?*

Individual/Sole proprietor

LLC

S Corporation

C Corporation

Partnership

Trust/Estate

Non-Profit

I am not yet registered with the state or unsure how to classify the practice/provider.

Have you obtained your business license for the states you’re wanting to practice?*

Yes

Have you obtained your Tax ID number aka EIN?*

Yes

Have you obtained your NPI number?*

Yes

Have you obtained a Certificate of Need (if applicable)?*

Yes

Have you been approved with any insurance companies, including Medicare or Medicaid? If so, please list them.*

Do you wish to contract with all available insurance plans serving the area you will be practicing in?*

Yes

Have you decided how you will be handling billing & coding?*

Have you obtained a license from Department of Health & Human Services?*

Yes

Please describe how we can assist you. Provide any details that you feel will help us complete your enrollments and/or credentialing.*

Make an Appointment: You will be able to choose from available Appointments on the next step. Hacer una cita: podrá elegir entre las citas disponibles en el siguiente paso.

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Insure One- Provider Enrollment General Request

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