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Legal Name (including d

Legal Name (including d 2025

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The document is an application form for organizations seeking to become network participants with Group Health Cooperative of Eau Claire. It collects essential information such as legal name, contact details, facility type, accreditation, and practitioner information. The form also outlines the process for credentialing and emphasizes that submission does not constitute a contract until all requirements are met.

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Click ‘Get Form’ to open the Legal Name (including d application form in the editor.
Begin by entering your Legal Name, including any 'doing business as' (d.b.a.) names in the designated field. Ensure accuracy for proper identification.
Fill in your Main Physical Location, including street address, city, state, and zip code. If you have additional locations, list them on page 2 of the form.
Complete the Main Mailing Address if it differs from your physical location. Provide a contact number and fax number for communication purposes.
Input your organizational NPI numbers and Federal Tax ID number. Indicate whether you are Wisconsin Medicaid certified and specify the counties served.
Select the type of facility you represent and provide details about the number of locations and licensed practitioners on subsequent pages.
List all accreditations and certifications relevant to your organization to enhance credibility.
Finally, review all information for accuracy before signing at the bottom of the form to verify that all details are correct.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do you write your legal name?

A persons legal name typically is the same as their personal name, comprising a given name and a surname. The order varies ing to culture and country.

How do you specify DBA?

Select a unique and compelling DBA name that aligns with the goals of having a fictitious name (such as ensuring brand cohesion) and complies with local regulations. Depending on your underlying entity type, your city or county office likely has information on its website about what your DBA can and cant include.

What is the proper way to list a DBA?

In order to register a California DBA, you need to file a fictitious business name (FBN) statement with the county clerks office in the county your business is located. Out-of-state companies conducting business in California that wish to use a fictitious name must file their FBN statements in Sacramento County.

What is a legal name and DBA?

An individual or business entity can also choose to conduct business under a name that is different than its legal name by filing a DBA. DBA stands for doing business as. A DBA name is also referred to as a trade name, assumed name, or fictitious business name.

Do you operate under a DBA name?

Not necessarily. While a sole proprietor can operate under their personal name, registering a DBA can allow them to conduct business under a company name while still retaining the sole proprietorship structure. This enables branding opportunities and can add a certain professional flair to operations.

What does your full legal name include?

Full legal name means an individuals first name(s), middle name(s), and last name(s) or surname without the use of initials or nicknames unless otherwise acceptable in Section 5.0 of this document.

Legal Name (including d 2025

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