NEW COUNSELOR INFORMATION

First and Last Name

Address: Street, City, State and Zip Code

Email Address

Phone Number

In order to receive and file claims under Counsel the following information is needed Bevill and associates uses stripe services for any self pay transactions. A voided check on the account you wish your funds dispersed to in is required

Are you set up as:

Individual

LLC

Checking Account Information:

Legal operating Name

Tax ID # or Social Security #

Routing Number

Account Number

Upload copy of void check

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Please uploads copies of the following:

Driver License

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Professional License

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Liability / Malpractice Face Sheet

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Biography – CV

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Picture For Website (Face Shot)

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General Practice Information

Counsol

Username: rmorris1

Password:

Phone

Talkroute

IOS and Android Apps available

Email

Username – Email Address:

rmorris@bevillandassociatesllc.com

Password:

Harper1!

Bevill and Associates Intranet:

https://bevillandassociates.com/intranet-2/

Password: Harper1!

NEW COUNSELOR INFORMATION

General Practice Information

Prior to sending please make sure you have a copy of the General Practice Information