Demographics

PLEASE COMPLETE THE FORM BELOW

After we receive this form, we can begin the in-network contracting process

Legal Entity Name

Practice Name/DBA

Tax ID Number

CAQH ID

Group/Entity NPI Number

Practice Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Practice Phone

(###)

###

####

Fax

(###)

###

####

Primary Doctor Name

First Name

Last Name

Primary Doctor Individual NPI Number

Date of Birth

Skip the next section if there is only one Doctor at your location.

2nd - Doctor Name (if applicable)

First Name

Last Name

2nd - Doctor Individual NPI Number (if applicable)

Date of Birth

Is your practice a Medicare DME supplier for Oral Appliance Therapy?

YES - I am a Non-Participating Medicare DME Supplier (medicare reimburses our patients directly)

YES - I am a Participating Medicare DME Supplier (medicare reimburses our practice directly)

NO - I am Not a Medicare DME Supplier

Medicare PTAN Number