CAREPLUS - ALIVI (MULITI USE CARD BENEFIT) PROVIDER SURVEY

Email:

Website:

	Practice Management System or Point of sale used at office and contact name / number of vendor
First Name
Last Name
Email ID

Credit/Debit card processing Merchant bank

	Credit Card/Debit Card processing Merchant Bank and contact name/number of Vendor
First Name
Last Name
Email ID

	Computer technology used at office	Operating System
Computer
Tablet

Tax ID

Bank Name

Bank Routing (9 digit)

Bank Account number

Bank address

Preferred mode of settlement

W9?

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