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Quote Information

Please provide information necessary about your business and the practitioners for enrollment so that we can prepare a service agreement proposal for your enrollment project. Please reach out to your sales representative if you have any questions about this form. As much detail as you can provide will help speed the onboarding process for your enrollment services.

First Name

Provide your name so we can attach your quote information to your record

Last Name

Provide your name so we can attach your quote information to your record

Do you provide services via Telehealth?(Required)

Yes, In addition to in-person services

Yes, we only provide services via telehealth

Telehealth Platform(Required)

What platform do you use for telehealth services?

Business Entity Information

Full Legal Business Name of Your Entity(Required)

As is on file with the IRS

Organization Type(Required)

Type of business organization under which you are conducting business

Tax ID number for the entity(Required)

EIN provided by the IRS as shown on your IRS Form SS-4 (Notice CP575). If you are operating as a sole proprietor it is recommended that you obtain an EIN instead of using your SSN.

Type 2 NPI for the business(Required)

**A TYPE 2 NPI IS REQUIREID if you operate under ANY type of business entity. If you do not have at type 2 NPI, we can obtain it for you. In which case just enter "Apply For". Enter "N/A" if you are a sole proprietor not operating under a business entity (you are NOT a sole proprietor if you formed an LLC, PLLC, PC, etc under which to conduct business)

Business Entity Formation Date

Date you formed your business entity. **Please do not leave this field blank if you have formed a business entity (Inc, LLC, PLLC, etc)

Business Entity Formation State

**Please choose the state in which you formed your business entity. Leave blank if you are operating as a sole proprietor

Business Website URL

Ownership Information

Please list full names of owners and percent ownership. For example "James Smith - 50% and John Doe - 50%". Or simply James Smith 100%"

Service Location Information

Service location(Required)

Street Address City State ZIP Code

This should be a location where patient visits occur. The address should not be a residence or a "virtual office". **BE SURE TO INCLUDE SUITE NUMBER**

Service Location COUNTY(Required)

Provide the COUNTY (NOT COUNTRY) in which your service location is located within your state

Service Location Phone(Required)

Enter the phone number patients call to reach your practice (for appointment scheduling etc)

Service Location Fax

Enter the fax number for the business if applicable

Service Location Hours(Required)

Provide the operating hours of this service location

Office Manager Information (if applicable)

Provide name, phone, email information for your office manager (if applicable)

Practice Limitations

Provide any details about practice limitations (ie gender, age, etc) that should be filed in CAQH and with payors

Billing Information

Billing information is provided to insurance networks and also loaded in CAQH. This should be the contact information where patients reach out if they have a question about their bill.

Do you use a billing company(Required)

Yes

No (In-House Billing)

Do you utilize the services of a third party billing company? If you are applying to Medicare, you will need the contact information AND Tax ID of the billing company.

Billing Company name(Required)

Billing Phone(Required)

Billing Email(Required)

Enrollment Project Information

Practitioners to be Enrolled (Please include NPI)(Required)

Provide the **Name, NPI, and Specialty** of each provider who needs enrollment applications (Example "John Doe, MD, 1234567890, Internal Medicine")

Payor Networks to Request Participation(Required)

Please provide a list of payors for which the above practitioners would like to request participation with. Separate by comma. You can add to this list at any time.

Primary Point of Contact for Onboarding(Required)

Who will our onboarding team reach out to to begin collecting enrollment information for the business entity and each practitioner. Please provide phone and email for the contact if it is someone other than you.

nCred Portal Users (other than above practitioners)

List name, title, email, phone for any other individuals who need access to the nCred portal for your enrollment project. You do not need to relist practitioners or office managers listed above.

Project Notes

Provide any additional notes about your project here

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Quote Information

Business Entity Information

Service Location Information

Billing Information

Enrollment Project Information

Looking For Customer Support?

Solutions

Company

Solutions

Your Role

Resources

About Us

Client Care Center

MSPs Apply Here