Fillable WebPT Signup Form o correctly configure your documentation (City of Oakland)

Fill Online, Printable, Fillable, Blank WebPT Signup Form o correctly configure your documentation (City of Oakland) Form

Use Fill to complete blank online CITY OF OAKLAND (CA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

WebPT Signup Form o correctly configure your documentation (City of Oakland)

On average this form takes 23 minutes to complete

The WebPT Signup Form o correctly configure your documentation (City of Oakland) form is 3 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 87 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Oakland

BROWSE CITY OF OAKLAND (CA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
WebPT Signup Form
TIN FORM | 2019 | Page 1 of 3
This document is proprietary and confidential. No one may share this document without expressed written consent from WebPT.
T
o correctly configure your documentation within WebPT, as well as any current or future billing integrations, we
need your Tax Identification Number(s) (TIN). Only the Company Owner may complete this form.
Company Name:
Company Owner Name:
Company Phone Number:
Please select one individual from your clinic who will be responsible for managing the onboarding process on your
end. If a therapist, include their Credentials, License Number, and Individual NPI.
Onboarding Point-of-Contact: Credentials:
Email/Phone: E / P
License Number: Individual NPI:
Note: The email address must be unique and have never been associated with a previous WebPT Username.
Number of EMR therapist licenses? ___________ Number of EMR assistant licenses? ___________
Do you bill using more than one (1) Tax ID Number for your company? (Check one): ☐ Yes ☐
No
Clinic Information
Please complete the following information for each of your clinic locations, including Tax ID Number. There are
additional Clinic Information fields on the following pages.
1
Clinic Name:
Clinic Street Address:
City, State, and ZIP Code:
Email:
Phone/Fax: P / F
Tax ID Number:
Group NPI#:
Continued Page 2
I confirm that the above information is true to the best of my knowledge and that I understand the
terms described above.
Company Owner Signature
Date
Company Owner Name
Please return this completed form by email to the individual who requested it or to success@webpt.com
click to sign
signature
click to edit
WebPT Signup Form
TIN FORM | 2019 | Page 2 of 3
This document is proprietary and confidential. No one may share this document without expressed written consent from WebPT.
Clinic Information cont.
2
Clinic Name:
Clinic Street Address:
City, State, and ZIP Code:
Email:
Phone/Fax: P / F
Tax ID Number:
Group NPI#:
3
Clinic Name:
Clinic Street Address:
City, State, and ZIP Code:
Email:
Phone/Fax: P / F
Tax ID Number:
Group NPI#:
4
Clinic Name:
Clinic Street Address:
City, State, and ZIP Code:
Email:
Phone/Fax: P / F
Tax ID Number:
Group NPI#:
5
Clinic Name:
Clinic Street Address:
City, State, and ZIP Code:
Email:
Phone/Fax: P / F
Tax ID Number:
Group NPI#:
WebPT Signup Form
TIN FORM | 2019 | Page 3 of 3
This document is proprietary and confidential. No one may share this document without expressed written consent from WebPT.
Clinic Information cont.
6
Clinic Name:
Clinic Street Address:
City, State, and ZIP Code:
Email:
Phone/Fax: P / F
Tax ID Number:
Group NPI#:
7
Clinic Name:
Clinic Street Address:
City, State, and ZIP Code:
Email:
Phone/Fax: P / F
Tax ID Number:
Group NPI#:
8
Clinic Name:
Clinic Street Address:
City, State, and ZIP Code:
Email:
Phone/Fax: P / F
Tax ID Number:
Group NPI#:
9
Clinic Name:
Clinic Street Address:
City, State, and ZIP Code:
Email:
Phone/Fax: P / F
Tax ID Number:
Group NPI#:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

WebPT Signup Form o correctly configure your documentation (City of Oakland)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document