New Provider Form - Revive Center for Wellness

PERSONAL INFORMATION

Full Legal Name *

Preferred Name

SSN *

Date of Birth *

Gender *

Graduate School & Year of Graduation *

Country of Birth *

State (Territory) of Birth *

Personal Phone Number *

Personal Email Address *

Address *

Address

City

State/Province

Zip/Postal

LLC INFORMATION

If you have created an LLC, and want your compensation to be paid to the corporation, please provide the LLC information.

Name of LLC

TID / EIN

State (Territory) of Incorporation

Address of LLC (if different from personal address)

City

State/Province

Zip/Postal

PROFESSIONAL INFORMATION

Professional License Type

Professional License #

Individual NPI #

CAQH #

CAQH Username

CAQH Password

PAYROLL & DIRECT DEPOSIT INFORMATION

Account Ownership

Personal Account

Business Account

Type of Account

Checking

Savings

Bank Name

Bank Account Number

Bank Routing Number

PREFERRED PASSWORD FOR SYSTEM ACCESS

Minimum of 8 Characters
At least 1 letter, number, special character
Can not start with a number or special character

Requested Password *

WEBSITE BIO

Please read the current BIOs on Revive's website and provide one for yourself:

ADDITIONAL INFORMATION

Please provide any additional information:

FILES TO DOWNLOAD, COMPLETE, AND UPLOAD

W9 for Payroll
W9 for Insurance Paneling

Please upload a copy of your passport or Driver's License, a copy of your certificate of insurance, both W9s, and a voided check for payroll

Maximum upload size: 16MB

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