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

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 *

PROFESSIONAL INFORMATION

Professional License Type

Professional License #

Individual NPI #

CAQH #

CAQH Username

CAQH Password

PRE-LICENSED CLINICIANS ONLY

Required Client Hours To License

Accrued Client Hours Towards License

Required Supervision Hours Towards License

Accrued Supervisor Hours Towards License

INTERNS ONLY

Required Total Client Hours To Graduation

Accrued Total Client Hours Towards Graduation

Required Relational Client Hours To Graduation

Accrued Relational Client Hours Towards Graduation

Required Supervision Hours Towards Graduation

Accrued Supervisor Hours Towards Graduation

Proposed Scheduled

PAYROLL & DIRECT DEPOSIT INFORMATION

Account Ownership

Personal Account

Business Account

Type of Account

Checking

Savings

Bank Name

Bank Account Number

Bank Routing Number

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

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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