Provider Info

Provider/Midwife Information:
Provider Name (no nicknames): Credentials: License Number: Date of Birth:

Billing Preference:
How would you prefer Innovative Medical Billing LLC to represent you and your practice? Please check which best fits your billing preference. Your account will be set up for reimbursements from the insurance companies determined by your choice of the following: Providers with no birth center (billing professional fees only): These options will be set up using you name as the business name. If you want your account to be set up using your Business name, please check the box below indicating your choice: Yes, when setting up my account, please use my business name: Providers with a birth center: *(if you want everything to run through the birth center, you would then take out your professional fees from there) (Facility claims cannot be billed with using a social security number, but must be billed using an Employee Identification Number (EIN)*

Billing Preference:

How would you prefer Innovative Medical Billing LLC to represent you and your practice? Please check which best fits your billing preference. Your account will be set up for reimbursements from the insurance companies determined by your choice of the following:

Providers with no birth center (billing professional fees only):

These options will be set up using you name as the business name. If you want your account to be set up using your Business name, please check the box below indicating your choice:

Yes, when setting up my account, please use my business name:

Providers with a birth center:

**(if you want everything to run through the birth center, you would then take out your professional fees from there)

(Facility claims cannot be billed with using a social security number, but must be billed using an Employee Identification Number (EIN)

Tax Identification/NPI:
Individual Tax Id Number: SSN: EIN: Group Tax Identification Number (EIN): Individual NPI #: Group/Business NPI #: Do you have a CLIA waiver? : Number: Please send IMBLLC a copy in order to bill labs for you.

Contact Information:
Mailing Address(where you want your checks sent): City: State: Zip: County: Physical Address(if your mailing address is a PO Box): City: State: Zip: County: Best phone # to reach you: Alternate phone #: Fax Number: Do we need to call before faxing? Yes No Email: Website:

Business Name/Birth Center:
Business Name (if applicable): Is this a Birth Center? Yes No If yes, what is the license number?: Type of Practice:

Insurance Company History:
Have you billed insurance companies previously? Yes No If yes, which companies: : Do any insurance companies have outdated demographic information for you in their system? Yes No If yes, major companies billed previously: Aetna Cigna UH BC/BS Medicaid Tricare (CNMs only) BC/BS PIN: Medicaid PIN: Other:

Pricing Information:
What is the average number of births per month/year? (insurance patients): What do you charge for a 59400 (Global OB, which includes all normal ante partum visits, delivery, and port partum visits)?: Do you need help determining what the average charge is for this code in your area? Yes No Will you be interested in having your practice set up for electronic EOB’s/ERA’s? Birth Centers only: When submitting your facility fees claims, how much do you want us to bill insurance for mom and for baby? Yes No

Pricing Information:

What is the average number of births per month/year? (insurance patients):
What do you charge for a 59400 (Global OB, which includes all normal ante partum visits, delivery, and port partum visits)?:
Do you need help determining what the average charge is for this code in your area? Yes No
Will you be interested in having your practice set up for electronic EOB’s/ERA’s?
Birth Centers only: When submitting your facility fees claims, how much do you want us to bill insurance for mom and for baby? Yes No

Other:
Is your computer a Mac or PC? Mac PC Is there an office assistant or birth assistant that would be given permission to discuss any portion of your practice with IMBLLC? Yes No. If so, who would this person or persons be?

PARTNER/EMPLOYEE INFORMATION: (IF APPLICABLE)
Partner Employee N/A (Note: If you share the same business name, address, and group tax ID another provider, they can be added to this application #. If you do not share the same tax ID, that provider will need to fill out a separate application and pay a separate set-up fee.) Provider Name: Credentials: License Number: Date of Birth: Best phone # to reach partner: Alternate phone : Fax Number: Do we need to call before faxing? Yes No Email Address: Website: Individual NPI #: Does your partner have a CLIA waiver? Yes No If yes, #: Billed insurance before? Yes No BC/BS PIN: Medicaid PIN: Other: Major companies billed previously: Aetna Cigna UHC BC/BS Medicaid Tricare(CNMs only) Do any insurance companies have your partner in their system with outdated demographics information? Yes No

PARTNER/EMPLOYEE INFORMATION: (IF APPLICABLE)

Partner Employee N/A
(Note: If you share the same business name, address, and group tax ID another provider, they can be added to this application #. If you do not share the same tax ID, that provider will need to fill out a separate application and pay a separate set-up fee.)
Provider Name:
Credentials:
License Number:
Date of Birth: Best phone # to reach partner:
Alternate phone :
Fax Number:
Do we need to call before faxing? Yes No
Email Address:
Website:
Individual NPI #:
Does your partner have a CLIA waiver? Yes No
If yes, #:
Billed insurance before? Yes No
BC/BS PIN: Medicaid PIN: Other:
Major companies billed previously: Aetna Cigna UHC BC/BS Medicaid Tricare(CNMs only)
Do any insurance companies have your partner in their system with outdated demographics information? Yes No

Important Note: We will use this information exactly how it appears on this form to send claims to the insurance companies and to contact you. Incorrect information could result in delayed payments and other problems . Please confirm that all information is accurate. Once the information has been entered into our system there will be a $250 fee for any major information changes to your account. These include: Provider Name, Business Name, Credentials, Mailing Address, Individual Tax Identification Number/EIN, Group Tax Identification Number/EIN, and NPI Number. There will be no fee to change your email address, phone, or fax number.

(By signing below I acknowledge that I have read the notice and am aware of the additional fees for any major changes to my account.)

Signature:
Date:
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