Lindsay Technical Consultants, Inc.
42496 Lindsay Drive
North Mankato, MN 56003
Tel: (507)947-3070 Fax: (612)234-4700
Email: denhelp@lindtech.com


Provider Enrollment Form
Type in your info, print, sign and then fax (or mail) the form to LTC - (612)234-4700.
All fields in bold type are mandatory. Signature is not required when submitted by a Billing Center.

Practice Name:

Street Address:
Street Address:
City:
State: Zip Code (Must be the full 9 digits): -

Contact: Email:

Federal Tax ID: Tax I.D. Type: Employer(EIN) or SSN

Telephone Number: Ext. Fax Number:

Provider/Doctor (name for claim filing):

UPIN/License#: Specialty: Sp.Code:

NPI (Individual)#: NPI (Group)#:

Taxonomy Code (Find your code): Medicare PTAN #:
Railroad Medicare PTAN #: DME PTAN #:

Practice Management Software:
Referred by:

Limitations of Liability and Disclaimer of Warranties. Lindsay Technical Consultants, Inc. (LTC) warrants that it will transmit, in a timely manner, the information submitted by the Provider in the form in which it is sent to LTC. This is the sole and exclusive warranty of LTC. LTC will provide its best effort assistance in resolving any problems that may arise in the process of transmission of such information. LTC is not responsible for any Medical, Dental or Insurance claim and the Provider retains all liability on such claims and will indemnify and hold LTC harmless on account of all such claims, including the reconciliation or adjustment of any claim. LTC will bill the Provider monthly. I/we authorize LTC to submit claim information on our behalf and subject to the terms of this agreement.

Signature: ___________________________________________ Date:___________________