New Client Data Form
 

 

Please have the following documents available as they need to be uploaded to complete this form:
 
 - State Licensing & Accreditation (JCAHO/CARF if applicable) for any and all locations *
 - Attending Physicians License *
 - Individual Therapist License (if applicable and billing under their license) *
 - Copies of ALL in network contracts *
 - CLIA Waivers (if applicable) *
 - Signed W9 *
 - Voided Check *

If Facility Needs to be Credentialed:

 - SS4 Form (This is a piece of paper from the IRS that confirms your Tax ID) *
 - City Business License *

 

* Indicates required fields

 
Primary Contact
Full Name * Position *
Phone Number * Email Address *
 
Executive Contact
Full Name * Position *
Phone Number * Email Address *
 
Accounting & Invoicing Contact
Full Name * Position *
Phone Number * Email Address *
 
Utilization Review Contact
Full Name * Position *
Phone Number * Email Address *
 
Other Information
Availity Account *           CAQH Account *                 
EHR Vendor* Email Provider (Gmail, Outlook 365, GoDaddy, etc) *
Enrolled for Electronic Funds Transfers?*             
 
Facility Information
Facility 1 Information Attending Physician/Medical Director for Facility 1
Facility Legal Name * Physician Name *
Facility DBA (if applicable) Physician NPI *
Facility NPI * Physician License # *
Facility TIN/EIN * Physician Address *
Facility Billing Address * Levels of Care*     
Please select all that apply 
 
Facility Service Address * Current Client Total*
Facility Primary Phone Number * Total Facility Client Capacity*
Facility Fax Number  Handicap Accessibility*
Please select all that apply 
p    
Medicare License Number

Client Genders*
Please select all that apply 
    
Business Hours*
Client Admission Age Limits*
If additional NPI or TIN are used, please fill in below
Facility 2 Information Attending Physician/Medical Director Information for Facility 2
Facility Legal Name Physician Name
Facility DBA (if applicable) Physician NPI
Facility NPI Physician License #
Facility TIN/EIN Physician Address
Facility Billing Address Levels of Care
Please select all that apply
 
Facility Service Address Current Client Total
Facility Primary Phone Number Total Facility Client Capacity
Facility Fax Number    
*If you have additional facilities please add them by filling out this form again after completion.

* Upload Required Documents *
 
  • State Licensing & Accreditation (JCAHO/CARF if applicable) for any and all locations *
  • Attending Physicians License *
  • Individual Therapist License (if applicable and billing under their license) *
  • Copies of ALL in network contracts *
  • CLIA Waivers (if applicable) *
  • Signed W9 *
  • Voided Check *
If Facility Needs to be Credentialed:
  • SS4 Form (This is a piece of paper from the IRS that confirms your Tax ID) *
  • City Business License *
Please gather all required documents and upload them securely using the "SECURE UPLOADER" below.
Attach all files above by clicking "Choose file" for each and when all have been chosen click "Upload". 
SECURE UPLOADER
 

 
Please check all entries for accuracy and ensure you have uploaded ALL of the required documents to us before completing this form.


When finished, click the "Complete Form" button below.
For support please call (800) 478-0233 or email info@zealie.com

We appreciate your business and look forward to serving you!