Requirements to Get Started

Provider Information Required
• Professional Providers Profile Sheet (completely filled out where applicable)

• Copies of each license and/or credential certificates

• W-9 Form

• Copies of other certificates or documents which are required to operate/manage.

• Copy of the Super Bill (includes CPT codes, Diagnosis codes and fee schedule); if applicable • Copies of Contractual Agreements with other Providers, if applicable ie: a patient only has Government insurance (Medicare, Medicaid, Champva, TriCare, all Medicare supplement
• Copy of patient registration and intake form

• Copy of insurance card (front and back)

• Copies of Explanation of Benefits (EOB) from previous submitted claims, if applicable

• Copy of patient payment’s, if applicable

• Any documents or form that relate to patient. Re: Financial Hardship Agreement, Workers
Compensation, etc

• Authorization and Precertification, if applicable Claim Billing Requirements

• Patient Super Bill stating diagnoses and procedure

• Face-sheets; signed name along with date of Procedure and if assisting in the procedure
with named surgeon/physician

• Operative Reports; if applicable

• Letter of Medical Necessity; if applicable

• CPT codes and Diagnosis codes; if assisting.

Any Additional work- per Separate Proposal

Payment less service fees will be sent to Providers by Check or Direct Deposit no earlier than two
(2) weeks pending payment of insurance claims by carriers, with itemized statement attached.