New Provider Form - Revive Center for Wellness

New Provider

New Revive providers need to complete the following form in order to be set up in the internal systems.

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

PROFESSIONAL INFORMATION

Professional License #

NPI #

CAQH #

Insurance (Already In-Network)

PAYROLL & DIRECT DEPOSIT INFORMATION

If you have created an LLC or corporation which you want to be paid through, please provide its name and federal EIN. The bank account information should also be an account opened in the name of the corporation. If you do not have a corporation you should include your personal bank account information.

Corporation Name

EIN

Bank Name

Bank Account Number

Bank Routing Number

PREFERRED PASSWORD

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

ADDITIONAL INFORMATION

Please provide any additional information:

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