850-926-­4200
Mental Health Billing Provider Form

Provider Information Form

* Indicates a required field

Provider Name and Credentials:*
Provider Specialty:*
Mailing Address:*
Phone:*
-
Physical Address:*
Fax #:
-
E-mail:
Federal I.D. #*
Social Security #:*
NPI Number:*
Group NPI:*
State License Number:*
Blue Shield Provider #:
Medicare Provider #:
Medicaid Provider # (if applicable):
Word Verification: