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Provider Registration Form
Please fill out the following sections completely:
Name of Provider's Office, Clinic, or Hospital:
Please enter provider name!
Phone Number:
Please enter phone number!
Provider Tax ID(s):
Please enter a tax ID!
Provide User Information (this user will be the account admin and can add addtional users):
First Name:
Please enter first name!
Last Name:
Please enter last name!
Email:
Please enter email address!
Position at the Provider's Office:
Select One
Physician
Office Manager
Nurse
Internal Biller
Coordinator
Office Staff
What Access Do you Require?
Claims and Provider Dispute Resolution Status
Referral Inquiry
Referral Submission