New Insurance Request Form

Request To Add New Insurance

Please fill out all required sections on this form and submit

MEDENT Account Number:*

Directory (if multiple directories):

Insurance Company Name:*

Street Address 1:*

Street Address 2:




Phone Number (must be in this format: xxx-xxx-xxxx)


Fax Number (must be in this format: xxx-xxx-xxxx):

Payer Id Number:

Workers Comp/No-Fault: If New Insurance Company is a Workers Comp or No-Fault Type please indicate which one:

Credential Type: * Please Indicate how the providers are credentialed with this Insurance company.

Midlevel Billing Requirements for this Insurance:If office has midlevel providers (Nurse Practitioners and/or Physician Assistants) how should their claims be submitted for this Insurance?

Additional Setup

Authorized Name:*


Contact Person:*

Contact Email:*

Phone:* Ext: