Client Forms | Trustegic Medical Billing Services, LLC

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HEALTH CARE PROVIDER INTAKE FORM

Practice Name:

Federal Tax ID:

Email

Street Address

Region/State/Province

Postal / Zip code

Phone

Fax

Medical Office Type

Provider NPI:

Group NPI:

CAQH Number

Claims are submitted

Check all that apply

Anthem Blue Cross Blue Shield

Aetna

Aetna Better Healthcare

Cigna

Sentara Healthcare

Healthkeepers Plus

United Healthcare

Molina Healthcare

Optima Health

Piedmont Community Healthcare

Virginia Premier Health Plan

Other

ARM

TELEHEALTH

BILLING & CODING

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