Instructions: Print this application. Complete one copy
Date: __________                                                          for each provider and/or location in your organization.

Physician/Provider Name __________________________________________________________________________

Medical Specialty ____________________________________________________Degree(s) ____________________

If a Group Practice, How many physicians or providers require our service ________________________________

At how many office locations do you see your patients?________________________________________________

Point-of-Contact for billing  Name ___________________________________________________________________

Title of POC __________________________________________ POC Phone Number _________________________
                              (Office Manager, Managing Partner, etc.)

Name of Practice _________________________________________________________________________________
                                      (if different from Applicant)

Street Address ___________________________________________________________________________________

Building and/or Suite _____________________________________________________________________________

City ________________________________________________ State __________________ Zip _________________

Phone ___________________________________________ Fax ___________________________________________

Email ___________________________________________________________________________________________

Medicare Provider Number  Individual# __________________________ Group# ____________________________

Blue Cross Provider Numbers  Individual# ________________________ Group# ____________________________

Date you wish 1st Medical Billing to begin billing operations ____________________________________________

Is your business an established or a new practice?  Established __________________New __________________

Who is currently doing your billing? ________________________________________________________________

Why are you changing your billing operations? _______________________________________________________

________________________________________________________________________________________________

Do you require credentialing?    Yes ________No_________                    

Thank you for completing this application. An operations manager will call you with a quote and a contract
will be forwarded to you for signature. The application process takes about two days. If you have any questions please call us.

1st Medical Billing • 5600 Lovers Lane, Suite 116-118 • Dallas, Texas 75209 • 866 701 1716
www.1stMedicalBilling.com                                                                          Operations@1stMedicalBilling.com