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To sign up, you'll need:
Create Your Salucro Account
Business Contact
Business Details
Control Individual
Beneficial Owner
Bank Information
Confirm Your Account Information
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Completing this sign-up form will allow us to capture the information needed to setup your Salucro account. Federal and other compliance obligations require us to collect this information for purpose of establishing your account, and also to verify ownership and control information. We make every attempt to request the minimum amount of information necessary for compliance obligations. Information you submit in this form will be kept strictly confidential and disclosed only to satisfy our compliance obligations and maintain your account. If you have any questions, please call Salucro Support at (866) 430-7333 option 2.
Information that will be requested includes:
Tax ID Number
NPI Number
Bank Information
Information about individuals who own and control the organization
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Please enter the information for the person completing this form
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Please select the legal structure of the organization, and enter the facility NPI (if applicable) and federal tax ID.
Mandatory compliance obligations require us to capture information about individuals who own at least 25% or more of the organization. We also need to collect information about the person with significant responsibility for managing the entity. For applicable individuals, we will require their name, personal address, date of birth, and social security number.
The submission of this form is secure, but please call Salucro Support at (866) 430-7333 option 2 if you would like to provide this information in an alternative way.
Provider type
Healthcare system
Hospital
Physician
Other
Company type
Individual/Sole proprietorship
Corporation
Limited liability company (LLC)
Partnership
Nonprofit entity
Government agency
Ownership type
Public
Private
How many individuals have an ownership interest directly or indirectly of at least 25% or more? Note that if an owner holds interest through a legal entity, we will still need the owner's individual information.
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1
2
3
4
Please provide the following information for an individual with significant responsibility for managing or directing the entity, including, an executive officer or senior manager (e.g., Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer)
Beneficial owner 1
Beneficial owner 2
Beneficial owner 3
Beneficial owner 4
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Bank account type
Checking
Savings
Thank you for successfully completing the Registration Signup Form. We will begin to process your account information. A Salucro Implementation Specialist will contact you if any additional information is required.
If you have any questions, please do not hesitate to contact our office at 866-430-7333 option 2. You may also contact us via Live Chat at www.salucro.com. Thank you again.
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