Provider & practice information form

1
Your name* This field is required.
First Name
Last Name
2
Your phone number* This field is required.
Area Code
Phone Number
3
Your email address* This field is required.
example@example.com
4
Your street address* This field is required.Where should insurers should mail checks and correspondence?
Street Address
Street Address Line 2
City
State
ZIP Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Your licensure/certification* This field is required.Please check all that apply.
CNM
CPM
LM
RM
IBCLC
Other
6
In which state(s) are you licensed to practice?* This field is required.
7
Your license number(s)* This field is required.
8
Your Social Security number (SSN) / Individual taxpayer identification number (ITIN)* This field is required.Please enter a nine-digit number without hyphens: either your Social Security number or your individual taxpayer identification number. If your practice has an employer identification number (EIN), please DO NOT enter it here -- you'll share it later in the form.
9
The number you entered on the previous screen is:* This field is required.
Your Social Security number
Your individual taxpayer identification number
10
Your NPI number* This field is required.
11
Are the correct addresses and phone numbers associated with your NPI number?* This field is required.Please look up your NPI at https://npiregistry.cms.hhs.gov/ and ensure that your mailing address, practice address, phone number, and fax number are correct.
Yes
No, I need to update this information
12
Are you contracted/in-network with any insurance companies?* This field is required.
Yes
No
13
With which insurance companies are you contracted/in-network?
14
Practice name (if applicable)
15
When we submit claims for your clients, which tax ID should we use?* This field is required.
Your individual SSN / TIN
Your practice EIN
16
Does your practice employ multiple providers?* This field is required.
Yes - If so, please submit a Provider & Practice Information form for each provider.
No
17
Practice employer identification number (EIN)Please enter a nine-digit number without hyphens.
18
Where does your practice provide care?* This field is required.Please check all that apply.
Clients' homes
Freestanding birth center
Office/clinic
19
Facility NPI number
20
Are the correct addresses and phone numbers associated with your facility NPI number?Please look up your facility NPI at https://npiregistry.cms.hhs.gov/ and ensure that the mailing address, practice address, phone number, and fax number are correct.
Yes
No, I need to update this information
21
Approximately how many insurance-billable births does your practice attend each year?* This field is required.
22
Additional services provided by your practice:Please check all that apply.
Well-person care (breast/chest exams, pelvic exams, Pap smears)
Lactation care
Fertility and conception care (ICIs, IUIs, consultations)
Other
23
Which services would you like Cohosh to provide?* This field is required.Please select an answer for each of the five rows (you may have to scroll down). For more information about our services, please visit the Services & Fees page of our website: https://cohoshbilling.com/services-and-fees
Yes
No
Verification of benefits
Row 0, Column 0
Row 0, Column 1
Gap exception requests and appeals
Row 1, Column 0
Row 1, Column 1
Claim preparation and submission
Row 2, Column 0
Row 2, Column 1
FSA, HSA, and HRA invoice preparation and submission
Row 3, Column 0
Row 3, Column 1
Client payment plans and collections
Row 4, Column 0
Row 4, Column 1
Verification of benefits
Gap exception requests and appeals
Claim preparation and submission
FSA, HSA, and HRA invoice preparation and submission
Client payment plans and collections
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
1 of 5
24
Who will be responsible for:* This field is required.Please select an answer for each of the three rows (you may have to scroll down).
Provider/practice
Provider's/practice's clients
Not applicable
The verification of benefits fee?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
The gap exception request or appeal fee?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
The claim preparation and submission fee?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
The verification of benefits fee?
The gap exception request or appeal fee?
The claim preparation and submission fee?
Provider/practice
Row 0, Column 0
Provider's/practice's clients
Row 0, Column 1
Not applicable
Row 0, Column 2
Provider/practice
Row 1, Column 0
Provider's/practice's clients
Row 1, Column 1
Not applicable
Row 1, Column 2
Provider/practice
Row 2, Column 0
Provider's/practice's clients
Row 2, Column 1
Not applicable
Row 2, Column 2
1 of 3
25
How will you provide the information necessary to prepare claims?* This field is required.
Access to electronic health record system
Completion of online superbill
26
Which electronic health record system do you use?
ClientCare
Maternity Neighborhood
Office Ally
Private Practice
Other
27
Please check the box below to agree to the following terms and conditions:* This field is required.
28
Your signature* This field is required.
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