Provider Matrix

Fill out the Provider Matrix and send it to us via email, using the form below:
[FrontPage Save Results Component]
Clinic Name:
Address:
City, State, Zip:
Phone:
Fax:
Check Writing Address
(if different)
City, State, Zip:
Physician Supplier Name:
Physicians Only:
(please check one)		 Sole Practice  Group Practice
Medicare ID:

Medicaid ID:
Medicare UPIN

Medicaid Pin:
Medicare PIN

BC/BS
Box 27: Medicare Participating Provider Assignment?Yes  No

BC/BS Pin:

R.R. Medicare:

Champus V/A:

EIN/Tax ID#:

SSN:
Other - Please list Payor Names and ID#'s:
Other Information

Provider Specialty:

Specialty Lic. #:

State Lic. #:

CLIA #:

Dentist Lic. #:

Anesthesia Lic.#:

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