Welcome to Glenn Billing; Billing for the Healthcare Industry

Professional Service Application Form

Please fill out the following information to help Glenn Billing understand your business' needs.

Name:

Position:

Practice Name:

Provider Name and Credentials:

License Type:

Number:

Tax ID Number:

or SSN:

Phone:

Alt. Phone:

Office Fax:

Email:

NPI Number:

Address:

Street:
City:		State:		Zip Code:

Billing Adress:

Street:
City:		State:		Zip Code:

Provider Numbers:

Medicare

Medicaid

BCBS

Tricare

Other

Add another provider

Please enter your most commonly used procedure codes and practice fee schedule:

CPT Code:

Practice Fee:

Add another code

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Word Verification: