Prospective Client Inquiry Form Full Legal Practice Name as shown on IRS Verification Letter: * DBA: * Name: * First Name Last Name Business Phone: * (###) ### #### Contact Email: * Type of organization: (Corp, PC, LLC, etc) * Tax ID #: * Type 1 NPI: * Type 2 NPI (if applicable): Taxonomy code: * State License #: * D.O.B: * MM DD YYYY Individual Medicare #: * Group Medicare # (if applicable): Primary Office Contact: * First Name Last Name Primary Office Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Office Phone: * (###) ### #### Primary Office Fax: (###) ### #### Primary Office Email: * Primary Office Hours and Days Opened: * Mailing Office Address: (if different from office address) Address 1 Address 2 City State/Province Zip/Postal Code Country Mailing Office Phone: (if different from office address) (###) ### #### Mailing Office Fax: (if different from office address) (###) ### #### Mailing Office Email: (if different from office address) Type of Practice: * Do you have any practice limitations: * Yes No Do you have Additional Office Locations? * Yes No If Yes Please list Address and Phone number if different: Networks that you are already credentialed with: * Networks that you would like all your practitioners credentialed with: * Owner 1 Details: * Individuals with Ownership Interest and Managing Control of the Supplier (List all owners of your business entity). The total ownership must equal 100%. Please provide: Full Name DOB SS # NPI Ownership % Owner 2 Details: Individuals with Ownership Interest and Managing Control of the Supplier (List all owners of your business entity). The total ownership must equal 100%. Please provide: Full Name DOB SS # NPI Ownership % Owner 3 Details: Individuals with Ownership Interest and Managing Control of the Supplier (List all owners of your business entity). The total ownership must equal 100%. Please provide: Full Name DOB SS # NPI Ownership % Owner 4 Details: Individuals with Ownership Interest and Managing Control of the Supplier (List all owners of your business entity). The total ownership must equal 100%. Please provide: Full Name DOB SS # NPI Ownership % Does an organization own part of this entity? * Yes No Thank you!
