NEW COUNSELOR INFORMATION Leave this field blank 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 PC Checking Account Information: Legal operating Name Tax ID # or Social Security # Routing Number Account Number Upload copy of void check Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Please uploads copies of the following: Driver License Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Professional License Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Liability / Malpractice Face Sheet Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Biography – CV Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Picture For Website (Face Shot) Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. General Practice Information Counsol Login: https://counsol.com/site/access/login/ 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! Prior to sending please make sure you have a copy of the General Practice Information Send