WEST COAST MEDICAL BILLING SERVICES

 

Physician’s Application

Name:

Home Address:        

Telephone:_______________________ Pager:________________________________

Office Address:        

Telephone:_______________________ Fax:_________________________________

Office Address:        

Telephone:_______________________ Fax:__________________________________

                   Primary Specialty:______________________________________________

                   Second Specialty:______________________________________________

                   Date of Birth:_____________ Driver’s license #________________________

                   Social Security #:__________ EIN #:________________________________

                   Doing Business As (DBA):________________________________________

                   Medical Licenses:______________________________________________

                                                                                                                                                            ____________________________________________________________

                   DEA #:_________________ UPIN:________________________________

                   Malpractice Insurance Company:___________________________________

                   Address: ________________ Policy #:______________________________

Hospital Privileges/Affiliation

                   Name:__________________ City:_________________________________

                   Name:__________________ City:_________________________________

                   Name:__________________ City:_________________________________

Laboratories Used:

                   Name:__________________ City:_________________________________

Curricula Vitae:

                   Medical School > Name:_________________________________________

                        Address:_________________________ Graduated (Mo/Yr)____________

                   Internship At > Name:____________________________________________

                        Address:_________________________ Graduated (Mo/Yr)_________________            

 

                   Residency At > Name:___________________________________________

                        Address:_________________________ Graduated (Mo/Yr)____________

                   Fellowship > Name:_____________________________________________

                        Address:_________________________ Graduated (Mo/Yr)____________

Participating Status:

                   Medicare:_______________ Active/Effective_________ Provider #________

                   Medi-Cal:_______________ Active/Effective_________ Provider #________

                   Champus:_______________ Active/Effective_________ Provider #________

                   Railroad Retiree:__________ Active/Effective_________ Provider #________

                   Blue Cross, CA:___________ Active/Effective_________ Provider #________

                   Blue Shield, CA:__________ Active/Effective_________ Provider #________

                   Others: Name:_________________________________ Provider #________

Previous Billing Agency(s)  (will enable our office to trace documents or complete follow-up if necessary)

Name:__________________________ Telephone #:___________________________

 

 

***Please submit copies of curricula vitae, social security card, driver’s license, medial license, medial degree(s) or continued education certificates and malpractice insurance face sheet.***

 

Certificate of applicant

I certify that statements made in this application re true and complete to the best of my knowledge. I understand that West Coast billing service will not be liable or accountable for any false statements or omissions made and this could constitute justifiable cause of the immediate termination of this agreement.

 

 

 

 

 Date:________________ Physician Signature:________________________________