Sign-up Form Office Name: * Address: * Phone: * Fax: * Email * NPI: * EIN: * Logo (send as attachment) Is this a facility/clinic or in-home office? * Go-live date (please give us a few date and time options to accommodate a training session): * For providers, please fill out the following: * Email (must be different than the office email): * NPI: * For administrators and non-clinical staff, please fill out the following. Email (must be different than the office email): Billing Enrollment, please fill out the following: * Individual or facility NPI of the credentialed entity Individual or facility PTAN (for Medicare) of the credentialed entity SSN or TaxID of the credentialed entity What Primary Insurance PayerID(s) do you need us to include? Including Medicare and any other insurances. Please see the attached file. Website/URL If you are human, leave this field blank. Submit
