Medicare Application

- Step 1 of 12

Name *

First

Last

The full name of the individual submitting this information form.

Phone *

Legal Business Name *

The legal name of the business used to report to the IRS

Name of Organization *

Doing Business As (DBA)

Organization Type *

Select your legal entity type

Tax Identification Number *

National Provider Identifier Standard (NPI 2) *

If you DO NOT have an Organizational National Provider Identifier - Please exit this form and complete the process to obtain one.2

Practice/Storage Location

Practice Address *

Address Line 1

Address Line 2

City

State

Zip Code

This is the physical address of your practice

Managing Employee or Authorized Official:

It is recommended that your managing employee or authorized official is the doctor/dentist making this application.

Name *

First

Last

Official Title *

Date of Birth *//

Country of Birth *

State of Birth *

Office Hours of Operation

Input the hours of operation at this location. Each day MUST have an entry. If you are closed enter "CLOSED"

Sunday *

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Saturday *

Bank Information for Electronic Funds Transfer

Medicare requires EFT to be enrolled.

Name of Bank Branch Contact Person *

First

Last

You must provide the contact information for your personal banker or branch manager of the branch where you bank.

Bank Contact Direct Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Address to local bank branch

Physician Information

Please provide the personal and professional information for the doctor/dentist

Prefix *

Legal Name *

First

Middle

Last

Suffix *

Other Suffix

Include all professional designations (DDS, DDSC, PhD, Etc.,)

Provider Individual NPI Number *

If you do not know your NPI Number, please visit https://npidb.org

Physician Date of Birth *//

Physician Country of Birth *

Physician State of Birth *

Physician/Dentist Social Security Number *

Name of Medical/Dental School *

Date of Graduation

State of License Issued *

License Effective Date

License Renewal Date

Do you currently accept Medicare patients? *

When did you accept your first Medicare patient?

NOTE: This may be an estimated date.

Business Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Your business mailing address must be a physical address and not a post office box.

Business Telephone Number *

Business Fax Number

Personal Email Address *

This MUST be the Doctor/Dentist personal email address

Final Adverse Legal Action *

Please describe final adverse legal action: *

Date

Taken By *

First

Last

Who handled the legal processing of the adverse legal action.

Upload Required Documents

You must upload the required documentation below when submitting this completed request. Valid and current copies are required. The current dates on these are important.

Dental License *

Click or drag a file to this area to upload.

Attach a current copy of your dental license

DEA Certificate *

Click or drag a file to this area to upload.

Attach a current copy of your DEA certificate

IRS FORM CP575 or IRS FORM 501C Tax Document *

Click or drag a file to this area to upload.

Attach a current copy of your IRS CP575 Tax Document

Voided Check *

Click or drag a file to this area to upload.

You MUST attach a copy of a voided check for the bank account where you want EFT payments to be deposited.

Bank Routing Number *

Bank Account Number *

Confirm Bank Account Number *

Purchase

Select the Medicare application services you want for this location and provider. Note: DME (Durable Medical Equipment such as sleep appliances) Part B covers procedures such as oral surgery, diagnostics and radiology.

Checkbox Items *

Medicare DME Non-Participating (Recommended) - $ 1,000.00
Medicare DME Participating - $ 1,000.00
Medicare Part B Non-Participating (Recommended) - $ 1,200.00
Medicare Part B Participating - $ 1,200.00
Non-Participating Bundle - $ 2,000.00
Participating Bundle - $ 2,000.00

NOTE: YOU MAY ONLY SELECT ONE DME AND ONE PART B APPLICATION.

I Accept

I understand that I will NOT be able to balance bill if I select DME Participating

Total

$ 0.00

Stripe Credit Card *

Card

Name on Card

NOTE: Application Fees are a one-time charge.

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