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One-Time Credit Card Payment Authorization Form

Medversant Technologies, LLC | 355 South Grand Avenue, Suite 1700 | Los Angeles, California 90071 | One-Time Credit card Payment Authorization Form Please sign and complete this form to authorize Medversant Technologies, LLC to make a One-Time debit to your Credit card , as listed below. By signing this form you give Medversant permission to debit your account for the amount indicated on or after the indicated date. Please fax the completed form to (877) 303-4078. Please complete the information be low: I, _____ , authorize Medversant Technologies, LLC to charge my Credit card (Full name ) account, as indicated below, for _____ on or after _____. This Payment is (Amount) (Date) for _____ for the Provider,_____.

Washington Practitioner Application – July 2013 Page 1 of 13 PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner …

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Transcription of One-Time Credit Card Payment Authorization Form

1 Medversant Technologies, LLC | 355 South Grand Avenue, Suite 1700 | Los Angeles, California 90071 | One-Time Credit card Payment Authorization Form Please sign and complete this form to authorize Medversant Technologies, LLC to make a One-Time debit to your Credit card , as listed below. By signing this form you give Medversant permission to debit your account for the amount indicated on or after the indicated date. Please fax the completed form to (877) 303-4078. Please complete the information be low: I, _____ , authorize Medversant Technologies, LLC to charge my Credit card (Full name ) account, as indicated below, for _____ on or after _____. This Payment is (Amount) (Date) for _____ for the Provider,_____.

2 (Description of goods/services) (Name of Provider) Billing Address _____ Phone#_____ City, State, Zip _____ Fax # _____ Email _____ Checking / Savings Account Credit card / Debit card Name on Account _____ Bank Name _____ Account Number _____ Bank Routing # _____ Bank City / State _____ Services Offered: 1. Paper Application Data Entry (Manual Data Entry) $30 PER APPLICATION, PER PROVIDER Quantity: _____ 2. Supporting Documents Scan & Upload (Indexing, Uploading and Record Matching) $15 PER REQUEST, PER PROVIDER Quantity: _____ 3. Application Review (Review of Application Completeness and Accuracy) $15 PER APPLICATION, PER PROVIDER Quantity: _____ SIGNATURE DATE I authorize Medversant Technologies, LLC to charge the Credit card indicated in this Authorization form according to the terms outlined above.

3 This Payment Authorization is for the goods/services described above, for the amount indicated above only, and is valid for One-Time use only. I certify that I am an authorized user of this Credit card and that I will not dispute the Payment with my Credit card company; so long as the transaction corresponds to the terms indicated in this form. VISA MasterCard AMEX Discover Cardholder Name _____ Account Number _____ Exp. Date _____ CVV _____ Medversant Technologies, LLC | 355 South Grand Avenue, Suite 1700 | Los Angeles, California 90071 | Supplement Form Additional Providers Please add your multi-provider listing on this page. Include their complete name and their login ID.

4 Select the type of service requested. Fax the completed form to (877) 303-4078. FULL NAME LOGIN NAME SERVICES 1. _ Data Entry Doc Upload App Review 2. _ Data Entry Doc Upload App Review 3. _ Data Entry Doc Upload App Review 4. _ Data Entry Doc Upload App Review 5. _ Data Entry Doc Upload App Review 6. _ Data Entry Doc Upload App Review 7. _ Data Entry Doc Upload App Review 8. _ Data Entry Doc Upload App Review 9. _ Data Entry Doc Upload App Review 10. _ Data Entry Doc Upload App Review 11. _ Data Entry Doc Upload App Review 12. _ Data Entry Doc Upload App Review 13. _ Data Entry Doc Upload App Review 14.

5 _ Data Entry Doc Upload App Review 15. _ Data Entry Doc Upload App Review 16. _ Data Entry Doc Upload App Review 17. _ Data Entry Doc Upload App Review 18. _ Data Entry Doc Upload App Review 19. _ Data Entry Doc Upload App Review 20. _ Data Entry Doc Upload App Review Washington Practitioner Application July 2013 Page 1 of 13 PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the application. Washington Practitioner Application To use the Washington Practitioner Application (WPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests.

6 When a request is received, send a copy of the completed application, making sure that all information is complete, current and accurate. Please sign and date pages 11 and 13 . Please document any YES responses on the Attestation Question page. Identify the health care related organization(s) to which this application is being submitted in the space provided below. Attach copies of requested documents each time the application is submitted. If changes must be made to the completed application, strike out the information and write in the modification, initial and date. If a section does not apply to you, please check the provided box at the top of the section.

7 Expect addendums from the requesting organizations for information not included on the WPA. This application is submitted to: 1. INSTRUCTIONS This form should be typed or legibly printed in black or blue ink. If more space is needed than provided on original, attach additional sheets and reference the question being answered. Please do not use abbreviations. Current copies of the following documents must be submitted with this application: (all are required for MDs, DOs; as applicable for other health practitioners). State Professional License(s) DEA Certificate ECFMG (if applicable) Face Sheet of Professional Liability Policy or Certificate Curriculum Vitae (Not an acceptable substitute for completing the application.)

8 ** All sections must be completed in their entirety. ** 2. PRACTITIONER INFORMATION Legal Name Required Last Name: (include suffix; Jr., Sr., III) First: Middle: Degree(s): List any other name(s) under which you have been known by reference, licensing and or educational institutions: Home Mailing Address: City: State: Zip Code: Home Telephone Number: ( ) Pager Number: ( ) Cell Phone Number: ( ) E-Mail Address: Birth Date: (mm/dd/yyyy) Birth Place (city, state, country): Citizenship: Social Security Number: Male Female Languages Fluently Spoken by Practitioner: Have you ever voluntarily opted-out of Medicare?

9 Yes No NPI: Medicare Number: (WA) Medicaid (DSHS) Number(s): L & I Number(s): Specialty primarily practicing: Sub specialties primarily practicing: Washington Practitioner Application July 2013 Page 2 of 13 PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the application. Other Professional Interests in Practice, Research, etc.: 3. PRACTICE INFORMATION CHECK ALL THAT APPLY Effective Date at Primary Practice location (MM/YY) _____ Practice Setting Clinic/Group Solo Practice Home Based Hospital Based Primary Care Site Urgent Care Other Practitioner Profile PCP Specialist Check if you are both PCP & OB OB in your practice Yes No Deliveries Yes No Name of Practice / Affiliation or Clinic Name: Department Name (if hospital based): Primary Office Street Address: City: State: Zip Code: Org.

10 NPI#: Patient Appointment Telephone Number: ( ) Fax Number: ( ) Mailing Address: (if different from above) Billing Address: (if different from above) Practice Website Office Manager / Administrator Name: Administration Telephone Number: ( )E-mail Address: Fax Number: ( ) Credentialing Contact (if different from above): Telephone Number: ( ) E-mail Address: Fax Number: ( ) Name Affiliated with Tax ID Number: Federal Tax ID Number: Is the office wheelchair accessible? Yes No Office Hours Are you accepting new patients? Yes No Have you limited your practice in any way ( 18 years or older?) Yes No If yes, please explain: _____ Do you currently supervise ARNP s or PA s?


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