US Bank Application

On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Enrollment and Numbers, click Enrollment Worklist. On the Enrollment Worklist page, in the Your Tasks section, click Forms. Locate the banking task (the Third Party Organization column is "US Bank") and click work next to the banking task.

You must have permission to complete tasks on the Enrollment Worklist. If your practice is assigned a U.S. Bank task on the Enrollment Worklist, athenahealth grants the Banking Task User role to the appropriate user at your practice and advises that user of the change.

To move from tab to tab, click Continue or Previous. To save the work you've done on a tab, click Save for Later. If you need more information about any item on a tab, click the Request help link.

To add or update a U.S. Bank account

 

You can update your practice's U.S. Bank account directly and securely in athenaOne. When you need to make administrative changes to your account (for example, changing the signer), athenaOne creates a banking task that appears in the Enrollment Worklist. (This task appears in the list when you open the Enrollment Worklist page.) You then update the information on the U.S. Bank Application page.

1. Display the Enrollment Worklist page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Enrollment and Numbers, click Enrollment Worklist.
   The task is displayed in the list.
2. Locate the banking task (under the Third Party Organization column, find "US Bank").
3. Click the arrow to the left of "US Bank" to expand the task.
4. Click work next to the banking task.
   The U.S. Bank Application page appears.
5. Update information in the fields as required.
6. Click Save.

The Practice Info tab displays your practice's general information, as well as billing and account information, and includes the following information.

General Practice Information

• Legal name — The office's legal name.
• Office address — The office's address.
• Office ZIP code — The office's ZIP code (if the Country field is not set to UNITED STATES, this field is labeled Office postal code).
• Office city — The city in which the office is located.
• Office state — The state in which the office is located (if the Office country field is not set to UNITED STATES, this field is labeled Office state or province).
• Office country — The country in which the office is located.
• Office phone number — The office's phone number.
• Office fax number — The office's fax number.
• Would you like a different statement address listed on the application? — Yes or No. If you select Yes, fields appear for the statement address (Address, ZIP code, City, State, and Country).
• Type of practice (select all that apply)— Medical practice, Hospital, Clinic, Federally Qualified Health Center (FQHC), Other.
• What year was your practice formed? — The year that the practice was formed.
• Does your company operate under any Doing Business As (DBA) names? — Yes or No. If this field is set to Yes, the following fields appear.
• DBA Name — Doing Business As (DBA) name.
• Is the DBA address the same as the practice's office address? — Yes or No. If this field is set to No, the following fields appear.
• DBA address — Doing Business As (DBA) office address.
• ZIP code — The DBA office's ZIP code (if the Country field is not set to UNITED STATES, this field is labeled Postal code).
• City — The city in which the DBA office is located.
• State — The state in which the DBA office is located (if the Country field is not set to UNITED STATES, this field is labeled State or province).
• Country — The country in which the DBA office is located.

Billing Numbers and Account Information

• Tax ID number (TIN) — The office's tax identification number (TIN).
• What business type applies to this TIN? — The business type that applies to the TIN.
  Note: The options in this menu map to the W-9 form.
• Select class of LLC — If you select Limited liability company (LLC) as the business type, the Select class of LLC field appears. Select C Corporation, S Corporation, or Partnership.
• Does your practice bill with a TIN, SSN, or both? — Select TIN, SSN, or both. If you select SSN, the following fields appear.
• Provider's first name — Enter the provider's first name.
• Provider's middle name — Enter the provider's middle name.
• Provider's last name — Enter the provider's last name.
• Provider's SSN — Enter the provider's Social Security number, or click Edit to change the number.
• Expected collections from cross-border checks — This U.S. dollar amount represents the money that you expect to collect from checks sent from outside the United States, for example, Mexico or Canada. Enter 0 if your practice does not collect cross-border checks.
• What is the estimated annual average of collections/revenue that will flow through this account? — The estimated annual average of revenue that flows through this bank account.
• What is the source of the funds for the checks you will be receiving? — Insurance payments, Patient payments, and Other.

The Practice Owner tab lists individuals or entities that own 25% or more of your practice. Any individual person listed on this tab must also be listed on the Account Signer tab. You can create up to four additional practice owners by clicking Add another owner at the bottom of the tab. Click delete to delete an owner.

The Practice Owner tab includes the following information.

• Does an individual or company own 25% or more of your practice? — Yes or No. If you select Yes, you must select the type of owner in the Type of owner field.

Type of owner field set to Person

• Percent owned — Percentage of the practice owned by this person.
• First name — The owner's first name.
• Middle initial — The owner's middle initial.
• Last name — The owner's last name.
• Job title — The owner's job title.
• Citizenship — The owner's citizenship status: U.S. citizen, Foreign, Resident alien, or Non-resident alien.
• Street address — The owner's street address.
• ZIP code — The owner's ZIP code (if the Country field is not set to UNITED STATES, this field is labeled Postal code).
• City — The city where the owner resides.
• State — The state where the owner resides (if the Country field is not set to UNITED STATES, this field is labeled State or province).
• Country — The country where the owner resides.
• Is this person politically exposed? — Yes or No.
• Driver's license, state, or federal ID — The practice owner's legal ID.
  Click Choose File to select and upload a scanned image of the ID.
• SSN — The owner's Social Security number (SSN). The SSN is required to create an account with U.S. Bank.

Type of owner field set to Private company

• Percent owned — Percentage of the practice owned by this company.
• Company name — Name of the private company.
• Relationship to your practice — Parent or Grandparent. Select Parent if the company directly owns the practice. Select Grandparent if the company owns the parent company.
• Street address — The company's street address.
• ZIP code — The company's ZIP code (if the Country field is not set to UNITED STATES, this field is labeled Postal code).
• City — The city in which the company is located.
• State — The state in which the company is located (if the Country field is not set to UNITED STATES, this field is labeled State or province).
• Country — The country where the company resides.
• Does any individual from the company own 25% or more of your practice? — Yes or No. If you select Yes, the following additional fields appear. If multiple people from the private company own 25% or more of the practice, fill out the fields for each additional owner.
• Percent owned — Enter the percentage of the practice that the person owns.
• Legal name — Enter the owner's legal name.
• Date of birth — Enter the owner's date of birth.
• Is this person politically exposed? — Select Yes or No.
• Driver's license, state, or federal ID — Upload the owner's identification document.
• Street address — Enter the owner's street address.
• ZIP code — Enter the owner's ZIP code (if the Country field is not set to UNITED STATES, this field is labeled Postal code).
• City — Enter the city where the owner resides.
• State — Select the state where the owner resides (if the Country field is not set to UNITED STATES, this field is labeled State or province).
• Country — Select the country where the owner resides.
• SSN — Enter the owner's Social Security number (SSN).

Type of owner field set to Board, publicly traded company, or government organization

• Percent owned — Enter the percentage of the practice that the entity owns.
• Entity name — Enter the entity's name.
• Relationship to your practice — Parent or Grandparent. Select Parent if the entity directly owns the practice. Select Grandparent if the directly owns the parent company.
• Country where entity was formed — Select the country where the entity was formed.
• Street address — Enter the entity's street address.
• ZIP code — Enter the entity's ZIP code (if the Country field is not set to UNITED STATES, this field is labeled Postal code).
• City — Enter the city in which the entity is located.
• State — Select the state in which the entity is located (if the Country field is not set to UNITED STATES, this field is labeled State or province).
• Country — Select the country where the entity resides.

Is this person politically exposed? field

 

A politically exposed person (PEP) is a current or former senior official or executive of any foreign government, political party, or government-owned enterprise (those with substantial authority over policy, operations, or use of government owned resources; a Consul General or senior administrative official). A PEP also includes relationships involving immediate family members or close associates.

 

The Account Signer tab must list individuals who own 25% or more of your practice. You can list up to 10 additional signers (create additional signers by clicking Add another signer at the bottom of the tab).

Note: If no individual owners (persons) are listed on the Practice Owner tab, you must enter at least two account signers on the Account Signer tab.

The Account Signer tab includes the following information.

• First name — The signer's first name.
• Middle initial — The signer's middle initial.
• Last name — The signer's last name.
• Job title — The signer's job title.
• Citizenship — The signer's citizenship status: U.S. citizen, Foreign, Resident alien, or Non-resident alien.
• Home address — The signer's home address.
• ZIP code — The signer's ZIP code (if the Country field is not set to UNITED STATES, this field is labeled Postal code).
• City — The city where the signer resides.
• State — The state where the signer resides (if the Country field is not set to UNITED STATES, this field is labeled State or province).
• Country — The country where the signer resides.
• SSN — The signer's Social Security number (SSN). The SSN is required to create an account with U.S. Bank.
• Email address — The signer's email address.
• Phone number — The signer's phone number.
• Fax number — The signer's fax number.
• Date of birth — The signer's date of birth.
• Signer types — The selected signer's types: Contract, Account, Treasury management.
• Is this person politically exposed? — Yes or No.
• Driver's license, state, or federal ID — The account signer's legal ID. Click Choose File to select and upload a scanned image of the ID.

Signer types field

 

You can select one or more signer types.

• Contract — A contract signer will attest to the accuracy of the athenahealth Master Services Agreement (MSA). This person has full access to the account. This authorization should be issued with care because it includes the ability to execute documentation that will add or remove authorized signers.
• Account — An authorized account signer can open, add, modify, or close accounts and sign checks, drafts, other orders of transfers, and so on.
• Treasury management — A treasury management signer can enter into Treasury Management Services, including signing additional required forms to implement or amend services.

Is this person politically exposed? field

 

A politically exposed person (PEP) is a current or former senior official or executive of any foreign government, political party, or government-owned enterprise (those with substantial authority over policy, operations, or use of government owned resources; a Consul General or senior administrative official). A PEP also includes relationships involving immediate family members or close associates.

 

The Account Officer tab lists one person who exercises direct control over, or entitlement to, the funds or assets in the account (that is, the Director or Executive Officer of a corporate entity).

The Account Officer tab includes the following information.

• First name — The officer's first name.
• Middle initial — The officer's middle initial.
• Last name — The officer's last name.
• Citizenship — The officer's citizenship status: U.S. citizen, Foreign, Resident alien, or Non-resident alien.
• Home address — The officer's home address.
• ZIP code — The officer's ZIP code (if the Country field is not set to UNITED STATES, this field is labeled Postal code).
• City — The city where the officer resides.
• State — The state where the officer resides (if the Country field is not set to UNITED STATES, this field is labeled State or province).
• Country — The country where the officer resides.
• Email address — The officer's email address.
• Date of birth — The officer's date of birth.
• SSN — The officer's Social Security number (SSN).
• Is this person politically exposed? — Yes or No.
• Driver's license, state, or federal ID — The account officer's legal ID. Click Choose File to select and upload a scanned image of the ID.

Is this person politically exposed? field

 

A politically exposed person (PEP) is a current or former senior official or executive of any foreign government, political party, or government-owned enterprise (those with substantial authority over policy, operations, or use of government owned resources; a Consul General or senior administrative official). A PEP also includes relationships involving immediate family members or close associates.

 

The System Administrators tab lists one or more people who receive the usernames and temporary passwords for all users and system administrators for this account. The System Administrators tab includes the following information for the primary contact at your practice and a second administrator. You can create an additional system administrator by clicking Add another system administrator at the bottom of the tab.

Primary Contact

• First name — The primary system administrator's first name.
• Middle initial — The primary system administrator's middle initial.
• Last name — The primary system administrator's last name.
• Address — The primary system administrator's home address.
• ZIP code — The primary system administrator's ZIP code (if the Country field is not set to UNITED STATES, this field is labeled Postal code).
• City — The city where the primary system administrator resides.
• State — The state where the primary system administrator resides (if the Country field is not set to UNITED STATES, this field is labeled State or province).
• Country — The country where the primary system administrator resides.
• Email address — The primary system administrator's email address.
• Phone number — The primary system administrator's phone number.
• Fax number — The primary system administrator's fax number.

Administrator 2

• First name — The secondary system administrator's first name.
• Middle initial — The secondary system administrator's middle initial.
• Last name — The secondary system administrator's last name.
• Email address — The secondary system administrator's email address.
• Phone number — The secondary system administrator's phone number.
• Fax number — The secondary system administrator's fax number.

The Documents tab includes the following information.

• W-9 form — The office's attached W-9 form.
• CP-575 form — The office's attached CP-575 form.
• Articles of Incorporation — The office's attached Articles of Incorporation document.
• DBA/Assumed Name Documentation — The office's attached DBA documentation.

To upload a form on the Documents tab

1. On the US Bank Application page, click the Documents tab.
2. Click Choose File.
3. Select the file to upload and then click Open.
   The file name appears to the right of the Choose File button.

After you enter and verify your U.S. bank information, click the Review and Submit tab.

• To submit your updated form, click Submit.
• To save your work and submit changes later, click Save for Later.