Agency Details - Majestic Billing Services LLC

Agency Details Form

In order to perform the Audit or onboard your Agency, we need the following information. Please take a few moments to gather the needed data and have it handy as you complete this form. It should take 5-15 minutes to complete the form.

We understand that the data we are needing is sensitive information, please rest assured this site is encrypted and your data is safe.

Agency Info

Medicare Info

Other Payer Info

EMR Info

Agency Legal Name

National Provider Identifier (NPI)

Tax ID

Current Census

Your Name

Your Title

Your Phone Number

Your Email

Agency Address

City, ST ZIP

PTAN

DDE Pin

DDE User ID

DDE Password

eServices User ID

eServices Password

iQIES User ID

iQIES Password

Current RCD Selection

Do you accept MA Plans? Do you accept Commercial (Managed Care) plans? Do you accept VA (TriWest or Optum UHC)? If Yes, please provide the payers you accept below: Do you accept Private Pay? Do you collect patient responsibility (Deductibles, Co-Insurance, Etc.)? All Fields Below Are Optional, But Will Help Us Perform The Audit.

Availity User ID

Availity Password

Waystar User ID

Waystar Password

UHC Portal User ID

UHC Portal Password

What EMR (Software) do you use? (Synergy, Axxess, WellSky, Cradle, etc.)

EMR User ID

EMR Password

Thank you very much for filling out this form! We look forward to working with you and your Agency!