F120-115-000 Statewide Payee Registration and W-9. F120-115-000 Statewide Payee Registration and W-9 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by selecting whether this is a NEW registration or a CHANGE to an existing registration. Check the appropriate box and complete the entire form, ensuring all relevant updates are noted.
  3. Enter your payee information, including the legal name as it appears on federal tax forms, SSN or EIN, business name (if applicable), contact details, and mailing address.
  4. Choose your preferred payment option: Direct Deposit or Check via US Mail. If opting for Direct Deposit, fill in your financial institution's details including routing and account numbers.
  5. Complete the W-9 section by entering your legal name, business name (if different), checking the appropriate IRS reporting type box, and providing your Taxpayer Identification Number (TIN).
  6. Finally, print, sign, scan, and email the completed form to ensure prompt processing. Alternatively, you can fax or mail it as instructed.

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You may need to consider backup withholding if a contractor refuses to provide a W-9. Backup withholding ensures that the appropriate taxes are paid to the IRS, even if the contractor does not comply with tax reporting requirements. As of mid-2024, the backup withholding rate is 24%.
If your business is a single-member LLC you MUST: List the name of the individual or the business/partnership who owns the LLC on line #1, List the name of the LLC on line #2, If an individual is listed on line #1, use their Social Security Number or if a business or partnership is listed on line #1 use their
Form W-9 can also be used to report other types of payments to the IRS, such as IRA contributions or mortgage interest. A W-9 doesnt include any tax withholding information because independent contractors are responsible for filing and paying their taxes unless they are subject to backup withholding.
The business that hires you should fill in its name and employer identification number (EIN). Youll then fill out the form line by line. This should be your full name. It should match the name on your individual tax return.
Thus, the W-9 Form plays a pivotal role in the revenue cycle and denial management of medical billing. Submitting W-9 Form provides the correct TIN (Tax Identification Number) of the providers to insurance companies, and consequently ensures timely reimbursement.
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The components of a W-9 form include: Name: Write your full name, including your first, last and middle, if applicable. Make sure your name is identical to the name you write on other tax forms.
For proper processing, information for disregarded entities is reported as the owners name on line 1, and the disregarded entitys name is entered on line 2.
If completing the form as a Partnership, multiple-member LLC, C Corporation or S Corporation, enter the name on line 1 as shown on the corresponding tax return as well as the business, trade or DBA name on line 2.

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