Therapist Information Form

Please submit the following information

This information is required for billing, setting up electronic remit deposits & patient record-keeping, and allowing patient online credit card payment option.

Please contact Andrea if you have questions: admin2@phawellness.com / (612) 299-1636.

  • e.g., Susan Jones, Sole proprietor, LLC, S Corp (Used for tax purposes, insurance company contracts, etc)
  • Required for automatic monthly billing for claims filing and record-keeping services.
  • Required for automatic monthly billing for claims filing and record-keeping services.
    Credit card numberExp date. (mo/yr)CVVS code 
  • Required for automatic insurance remit deposits & patient record-keeping
    Bank nameAccount numberRouting number 
  • Required to allow patient online credit card payments.