Billing Intake Form - Emerge and See

Transition Notes & Important Dates

Please let us know about any upcoming events, deadlines, or circumstances that may affect your billing transition or implementation. Examples include your current billing company's termination date, software conversions, office moves, staffing changes, or other important information.

EHR, Practice Management, Clearinghouse & Technology Access

System Access & Login Credentials

Please provide access to all systems required for Emerge and See to perform billing services.

Access may be provided by either:

Creating a dedicated user account for Emerge and See, which is preferred whenever available.
Providing an existing username and password in the fields below.

Please complete all applicable information.

Submitter / Account ID

Patient Portal Software

Whenever possible, Emerge and See recommends creating a dedicated user account for our team. If this is not possible, existing login credentials may be provided.

All information submitted through this form will be used solely to perform contracted billing services and will be maintained in accordance with our security policies and applicable HIPAA requirements.

Upload Voided Check or Bank Letter(Required)

Max. file size: 800 MB.

Upload W-9(Required)

Need a copy of the W-9? Download it here

The W-9 must list the group’s pay-to/remittance address and be signed and dated by the Authorized Official.

Max. file size: 800 MB.