C.L. Frates and Company

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Third Party Administration

Please complete this form and submit if you would like to establish a Trading Partner relationship with C.L. Frates and Company.
Items indicated with * are required.

Name of Covered Entity or Proposed Trading Partner*

Type of entity Provider
Clearinghouse
Other

For Providers only:
Name of your billing/practice management software vendor

Taxpayer Identification Number

Contact Person*

Phone:* Hours available:*

E-Mail address:

Are you using a clearinghouse?Yes
No
Name of your Clearinghouse if applicable:

Contact at your Clearinghouse

Phone Number

If you prefer to mail or fax the information, please click here to download a printable (PDF) version of this form. Adobe Acrobat Reader is required.

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All information provided is for C.L. Frates and Company use and will not be sold or distributed.