New Insurance Form

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:

City:*

State:*

Zip:*

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:

Workers Compensation
No-Fault

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

Group
Individual

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?

Rendering Provider ONLY (Midlevel will be the servicing provider on the claim)

Supervising Provider ONLY (Midlevel name will NOT be sent on the claim)

Supervising & Rendering (Both Midlevel and Supervising providers will be sent on the claim)

Incident to (during charge entry the user will be asked if claim is Incident to, Yes = Doctor Only on claim, No = Midlevel Only on claim)

Additional Setup

Authorized Name:*

Signature (by checking this box you are signing this document)*

Contact Person:*

Contact Email:*

Phone:* Ext: