M2H Provider Registration & Verification Data Coll

Money Squared for Health Provider Registration & Verification Information:

Welcome to Money Squared to Health. In order to simplify the provider enrollment process, we have created an online form for you to use to enter your provider information. A short account validation form is required for anti-fraud purposes to validate the deposit account you choose Money2 deposits to be made to. This simple process requires single point of contact for information gathering as well signature by authorized employee (Often a senior staff member in the treasury).
Should you have any questions as you are completing the form, please reach out to your dedicated Citi Sales representative. This process should take approximately 30 minutes to complete.

I Agree

Today's Date

* Provider Organization (Legal Name) :

* Provider Type :

* Address 1 :

Address 2 :

* City :

* State :

* Zip :

* Point of Contact Phone Number :

Point of Contact Email Address :

Provider ID Information

TAX ID :
NPI :

How often do you conduct surveys?

Tax ID (Tax reporting ID for DDA account to be used)

National Provider Identifier # (NPI)