top of page

​Forms

 

Where applicable, the appropriate forms/contracts will be available.

*Please Note:

  • ALL of these forms are considered CONFIDENTIAL material.

  • When you fill a form out, sign and date it, attach the form to an e-mail.

  • Scan and send: Insurance Card images (Front & Back), HIPAA forms, Demographic forms.

  • Send the e-mails / scans to dataipomail@gmail.com the SUBJECT must contain CONFIDENTIAL.   Thank you in advance!

*Medical Credentialing Forms
  • Statement of Work (with HIPAA Service Agreement, only clients see)
​

Basic Credentialing Form (get your CAQH ID, Set Up your Profile)

*Medical Data Forms
  • Statement of Work (with HIPAA Service Agreement form, only clients see)
​
  • Office Forms ( Custom Create for you = $5.00 per form):
    • HIPAA Form
    • Demographic Form (custom)
    • No Show/ Cancellation Form (custom)
    • Self Pay Agreement Form (custom)

  • Provider Set Up Form

  • Fee Schedule Form

  • Insurances - Temporary ID & Password  Form

  • HIPAA Form (Blank, fill out for):

1. New Clients

2. Returning Clients (after 1 year)

3. For each client, every  new Year

  • Provider_List of Client Visits Form

bottom of page