Forms

Contract

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Contract for Billing & Credentialing Services

Please email jdyer@dyermedicalbilling.com


 

Provider Enrollment & Group Enrollment

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  • New Client Entity Information Form - Must be filled out / Type N/A if it does not pertain to you
  • Practitioner Credentialing Application - Must be filled out  

  • Type N/A if it does not pertain to you



Documents Needed

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  • Specialties and Board Certification
  • Hospital Affiliation Information
  • Malpractice Insurance Information
  • Work History and References
  • Disclosure and Malpractice History
  • Basic Personal Information
  • A clear copy of all license and certificates are required
    • IRS Form W-9(s) & Verification LTR
    • Drug Enforcement Administration (DEA) Certificate
    • Controlled and Dangerous Substances (CDS) Certificate
    • State medical license(s)
    • Various identification numbers (UPIN, Medicare, Medicaid etc)
    • Malpractice insurance policy(ies)