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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.      Click here for downloadable form.

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.

Download Adobe Acrobat Reader

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