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Form W-9 (Rev. March 2024) Department of the Treasury
Internal Revenue Service

Request for Taxpayer
Identification Number and Certification

Go to www.irs.gov/FormW9 for instructions and the latest information.

Give form to the requester. Do not send to the IRS.

Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.

1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner's name on line 1, and enter the business/disregarded entity's name on line 2.)

2 Business name/disregarded entity name, if different from above

3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate

LLC. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)

Other (see instructions)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

(Applies to accounts maintained outside the United States.)

5 Address (number, street, and apt. or suite no.). See instructions.

Requester's name and address (optional)

6 City, state, and ZIP code

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN).

Social security number

– –

Employer identification number

–

Part II Certification

Under penalties of perjury, I certify that:

The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
I am a U.S. citizen or other U.S. person (defined below); and
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Sign Here

Signature of U.S. person

Date

#	Field Name	Type	Options / Format	Description
1	First Name	text	—	Patient's legal first name as it appears on their ID
2	Date of Birth	date	MM/DD/YYYY	Used for identity verification and medical records
3	Gender	radio	Male, Female, Other	Biological sex for medical assessment purposes
4	Primary Insurance Type	radio	HMO, PPO, Medicare, Other	Type of health insurance coverage the patient currently holds
5	Social Security Number	text	XXX-XX-XXXX	Required for insurance billing and records
6	Marital Status	radio	Single, Married, Divorced, ...	May affect insurance and emergency contact info

Request for Taxpayer
Identification Number and Certification

Patient Intake Form

Patient Details

Primary Insurance Policy

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Request for TaxpayerIdentification Number and Certification

Patient Intake Form

Patient Details

Primary Insurance Policy

Build Your Own Form Assistant

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Request for Taxpayer
Identification Number and Certification