Group Enrollment Onboarding Form

Please complete all sections accurately.

Business Information

Legal Business Name (as per IRS Letter) *

DBA (Doing Business As)

NPI *

TIN *

Old TIN (if applicable)

Contact & Address

Primary Address *

Billing/Correspondence Address *

All Service Location Addresses

Phone *

Fax

Company Email *

Operational Details

Ownership (Names, DOB, SSN, Home Address, Percentage)

Authorized Signer for Contracts

Primary Office Contact

How does the group file taxes?

Does the group have Medicare/Medicaid? In what states?

Portal Information (Medicaid, Availity, EyeMed, etc.)

Telehealth Services (Audio/Video)

Billing / CPT Codes

Video Platforms Used (Google, Simple Practice, etc.)

After-Hours Answering Service Details

Disclosures

Any Additional Notes

Payers You'd Like to Be Credentialed With

Enter one company in the box below, check the boxes for Medicare, Medicaid, and/or Commercial, then click Add Insurance. Repeat this for each individual payer you wish to credential with.

Insurance Company Name

Contract Type(s) Requested

Medicare Advantage HMO Medicare Advantage PPO Medicaid Commercial

Required Documents

Please be prepared to provide the following documents. You will receive a separate secure link for uploading.

Company Letterhead
IRS Letter (CP-575)
Licenses/Certificates
Fictitious Business Letter (if applicable)
Voided Check/Bank Letter
Certificate of Insurance (COI)
Articles of Incorporation
Bill of Sale (if applicable)
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