Superior RCM Solutions
Provider Enrollment Intake
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Welcome!
This form is for providers who are already credentialed and need to be enrolled with one or more insurance payers. Enrollment is the process of activating your billing privileges with each payer so you can begin submitting claims and receiving payment.
If you are a new provider who has not yet been credentialed, please reach out to Andrea as you will need to use our Credentialing Intake Form instead.
Before you start, have the following nearby: your CAQH ProView login, NPI confirmation, current malpractice declarations page, W-9, and any existing payer contracts or welcome letters.
This form saves your progress automatically as you go — feel free to complete it in more than one sitting. Fill out the sections below, upload your documents at the end, and submit when everything's ready.
All information submitted is kept strictly confidential and used solely for enrollment purposes in accordance with our HIPAA privacy practices.
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Practice/Group Information
Legal name of the practice or group. Solo providers use your legal name.
Please enter your practice or group name.
Only if billing under a group. Leave blank if solo practice billing under individual NPI.
Federal Tax ID used for billing. Solo providers may use SSN — indicate which.
Please enter your Tax ID.
Please indicate EIN or SSN.
Practice Address
Physical location where you see patients. Cannot be a P.O. Box.
Please enter the practice address.
Please enter the city.
Please enter the state.
Please enter the ZIP code.
Billing / Pay-To Address (if different from practice address)
Address where payers will send paper checks and correspondence. Leave blank if same as practice address.
If you see patients at multiple locations and want to enroll at more than one, select Yes. Each location may need to be enrolled separately with payers.
Please select an option.
Main phone number listed on payer applications
Please enter the practice phone.
Required by most payers for correspondence
Please enter the practice fax.
General practice email if different from personal email
Optional — some payers request this on applications
Some payers ask for availability. Example: Mon–Fri 9am–5pm
Current Enrollment Status
Username only. You will be asked to add Superior RCM Solutions as an Authorized Representative in CAQH ProView before work begins.
Please enter your CAQH username.
Your CAQH profile must be fully updated and attested before enrollment applications can be submitted. If it is expired or incomplete we will need to update it first.
Please select an option.
Your Provider Transaction Access Number issued by Medicare. Leave blank if you have never been enrolled in Medicare.
Your NC Medicaid provider ID. Leave blank if you have never been enrolled in NC Medicaid.
Select Yes if you already have active enrollment with any insurance payers. This helps us understand your starting point and avoid duplicate applications.
Please select an option.
If someone else has been managing your enrollment and you are switching to Superior RCM Solutions, select Yes. This helps us know what records and portal access we need to transfer.
Please select an option.
Payer Enrollment Selection
Select all commercial payers you need to be enrolled with. If you are already enrolled with any of these, you do not need to select them unless your enrollment needs to be updated or transferred.
Please select at least one commercial payer, or Other.
Note: Medicare and Medicaid enrollment can take 90–120 days. If you are already enrolled and simply need to transfer or update your enrollment, select them here and indicate that in the notes field below.
Please select at least one government payer, or none if not applicable.
Enter your active professional license number.
Please enter your state license number.
Additional Notes
Use this space for "Other" credential specifics, payer transfer details, or anything else that doesn't fit above.
Document Upload
Upload clear photos or PDF scans of each document below. Accepted formats: PDF, JPG, PNG (max 15MB per file).
NPI Confirmation Letter *
Your NPPES confirmation letter showing your NPI and taxonomy.
Malpractice Declarations Page *
The declarations page of your current malpractice insurance policy.
W-9 *
A completed, signed W-9 for the practice/billing entity.
Existing Payer Contracts / Welcome Letters
If applicable — you can upload more than one file.
Your progress is saved automatically. You can close this page and come back to this same link anytime before submitting.