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Client ID
Practice / Provider
Contact
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Status
NPI (Ind.)
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Monthly Fee
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Client ID
Contract Status
Prospective
Onboarding
Active
On Hold
Terminated
Inactive
Practice Name *
Provider Name
Services *
Billing Only
Credentialing Only
Billing + Credentialing
Credentialing Maintenance
Consulting
Credentialing Maintenance active
(generates monthly invoice)
Email
Contract Start
Individual NPI (Type 1)
Group NPI (Type 2)
Provider / Practice Details
Phone
Fax
Website
Practice Address
City
State
Home Address
Billing Address
🔒 The fields below are visible to Admin users only.
Tax ID
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EIN
SSN
Monthly Fee
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Service Changes / Termination
Service Change Date
Date services were downgraded (e.g. dropped credentialing)
Previous Services
Termination Notice Date
Notice Period
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60 Days
90 Days
Custom
Termination Effective Date
(auto-calculated)
Termination Reason
Notes
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Full Name *
Role
4-Digit PIN *
Access Level
Staff (standard)
Admin (sees sensitive fields)
Active
Active
Inactive
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