Getting Started – Peerless Med Bill Solutions, LLC

You have made the decision to outsource your billing needs to Peerless. You will need to complete the following information in order to get started: the Provider Enrollment Form and the Business Associates Addendum. In addition to those 2 forms, we will need the following documentation from your office:

Signed Business Agreement
Current W-9 (for all providers)

For your convenience, Peerless accepts Visa, MasterCard, Discover and American Express. If you are paying by credit card you will receive an invoice on the first of each month and your credit card will be billed on the 10th of the month. Please complete the Credit Card Authorization form and fax or email to Peerless.

Thank you for choosing Peerless Med Bill Solutions to take care of your billing needs. We look forward to a long and prosperous business relationship.

Credit Card Authorization Form

We are pleased to provide you with a number of payment options. If you are interested in having your charges billed to your credit card on a monthly basis, please complete this form and return it to Peerless Med Bill Solutions. LLC. You will be emailed a statement on the 1st of each month detailing your charges. Your credit card will then be billed 10th of the month.
Name on Credit Card
Practice Name
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
I hereby authorize Peerless Med Bill Solutions to process charges reflected on my monthly invoice against the credit card provided above. I realize I will be provided a statement in advance of these charges being processed. If a different form of payment is received prior to the 10th, this card will not be charged. Change in credit card information requires a new form to be completed prior to the date processing (10th of the month.)