What you will need to send me:
1.) A copy of your IRS Letter (Form CP 575)
2.) A copy of a voided check from your business bank account. (This check must be a regular business check. It must have your business name at the top left corner along with a check number at the top right and that same check number at the bottom near your routing number and account number.) Medicare will not accept starter checks.
3.) You will need a signed CMS 460 Participating Agreement form. I will send this form to you ready for your signature once I have your business NPI available.
Additional Information:
4.) Are you only treating patients in the patient’s home or in a clinic you own, rent, or lease?
If you are only treating patients in the patient’s home I will need your home address or business address.
If you will be treating patients in a clinic I will need that clinic address.
Include phone number and preferred email address.
5.) The full name of the school from which you graduated and the year in which you graduated.
