OFFICE VERIFICATION FORM (OVF)

Practice/Office Name

ADD A GROUP/TYPE II NPI # ADD A GROUP/TYPE II NPI # YES NO NOT SURE IF WE HAVE ONE

GROUP NPI#

WE HAVE MORE DOCTORS WE HAVE MORE DOCTORS YES NO

PLEASE LIST ADDITIONAL DOCTOR'S NAME FOLLOWED BY THEIR NPI#

We have an In-House Plan We have an In-House Plan YES NO

I AM INTERESTED IN HAVING AN IN-HOUSE PLAN BUILT I AM INTERESTED IN HAVING AN IN-HOUSE PLAN BUILT YES NO

OUR OFFICE RECEIVES CAPITATION PAYMENTS OUR OFFICE RECEIVES CAPITATION PAYMENTS YES NO

ADD AN ADDITIONAL TIN/EIN ADD AN ADDITIONAL TIN/EIN YES NO

ADDITIONAL TIN/EIN#

ADD ADDITOINAL LOCATION ADDRESS ADD ADDITOINAL LOCATION ADDRESS YES NO

ADDITIONAL LOCATIONS (LISTED: PRACTICE NAME/ADDRESS/CITY/STATE/ZIP)

Is there anything else you would like us to know?