PHYSICIAN REGISTRATION FORM1

PHYSICIAN REGISTRATION FORM1

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PHYSICIAN REGISTRATION FORM1
  • PHYSICIAN ENROLLMENT FORM:

    Please complete the Practice Registration Form with as much information as possible.  If you have not already done so please print off the Acknowledgement and Signature Form and have each physician sign and upload it at the bottom of this page.

    Supply Orders
    Supplies on all new accounts will be shipped out the same day if the order is in before 1:00pm CT via overnight express shipping. Please NOTE supplies will be shipped to arrive at anytime the day after they are shipped between 9:00am and 3:00pm to the practice.

    Print the Acknowledgement and Signature Form.

  • ACCOUNT MANAGER INFORMATION:

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  • PRACTICE AND PHYSICIAN INFORMATION:

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  • Insurance Mix

    If you don't know please estimate and put a "0" (zero) if it does not apply.

  • OFFICE CONTACT INFORMATION:

  • COLLECTOR INFORMATION:

  • REPORTING PORTAL INFORMATION (Web - Secure Portal) MUST BE STAFF MEMBER:

  • SUPPLIES

  • All supplies will be shipped to the primary practice address above unless specified below.
    If they have multiple locations please specify the supply order instructions in the "comments" section below.

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    Pick a Date
  • UPLOAD Signature Form
  • Should be Empty:
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