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Company Information
Step 1 - Company
To get started, please provide us with the following information
Note: To navigate around these registration pages please use the "BACK" and "CONTINUE" buttons.
I am a billing service submitting claims for one or more providers
Practice Information
Company Name:
Profession:
Dental
Medical (All Specialties)
Address 1:
Address 2: (optional)
City:
State:
Zip:
Contact Name:
E-mail:
Telephone:
Fax: (optional)
Group Specialty/Taxonomy Code: (Individual Code if no Group) (Note: Please select the same specialty/taxonomy you used to register your NPI.):
Group Tax ID: (Individual ID if no group)
This is your :
Fed. ID #
Soc. Security #
Group NPI (Individual NPI if no group):
Attachment Facility ID:
Name of Software:
Software Version:
Sales Person: (if applicable)
Sales Code: (if applicable)
Champions Code: (if applicable)
How many providers are at this location?
None (Ancillary Healthcare Services)
Provider First Name
MI
Last Name
Services
Please check the services for which you would like to register For a quick explanation of each service put your cursor over the link below. For a more detailed explanation click the link.
eClaims (Electronic Claims)
eStatements (Electronic Patient Statements)
eChecks (Electronic Patient Payment System)
eEligibility (Electronic Eligibility)
Create Username and Password
User Name:
Password: (6 - 16 characters)
Confirm password:
Note: Password is case sensitive and must include at least one letter (A-Z, a-z) and one number (0-9)
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