MED JAAF WELLNESS SOLUTIONS

1. Provider Information

Full Name *

The following PHI fields are encrypted in transit and at rest per HIPAA requirements.

SSN (Last 4)

Date of Birth

Percentage of Ownership

NPPES Credentials: For your security, our team will collect your NPPES login credentials through a secure, encrypted channel after your enrollment is approved. We never collect third-party passwords through public forms.

Speciality

Email Address *

Cell No.

2. Facility Details

Facility/Agency Name

Tax ID

NPI Type 1 (Individual)

NPI Type 2 (group)

Primary Service Address

Pay to Address

Mailing Address

Office Hours at location

Appointment Phone No.

Fax No.

Office Email

Office Manager/Contact

CAQH logins

3. Compliance Documents

You can add anything else you'd like, but please make sure to include the IRS option — it's required.

Document upload will be available after your enrollment is approved. Our team will contact you to collect required documents securely.

State License *

IRS Letter *Compulsory

Accreditation Letter

Malpractice/PLI/COI *

W9 Form *

Voided Check/Bank Letter *

Owner Driving License *

Resume / CV *

Write Other Insurance Company that you want to be registered that are not mentioned in our list

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Messages may include credentialing updates, enrollment status, appointment reminders, and service information.
Message frequency varies, up to 4 messages per month.
Message and data rates may apply.
Consent is not a condition of purchase or enrollment.
You can unsubscribe at any time by replying STOP. Reply HELP for help.

Provider/Facility Details

1. Provider Information

2. Facility Details

3. Compliance Documents

You can add anything else you'd like, but please make sure to include the IRS option — it's required.

4. Insurance Selection

Provider/Facility Details

1. Provider Information

2. Facility Details

3. Compliance Documents

You can add anything else you'd like, but please make sure to include the IRS option — it's required.

4. Insurance Selection

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