Provider Application

1 Business information

2 Professional information

3 Payment information

Business information

Note: This application requires the following information: bank account and routing number, NPI number and the last 4 digits of your SSN. Please have it ready before you start the application.

All fields are mandatory unless noted.

Start typing address. Click on correct location. The address information is automatically captured below. If needed, edit information in fields below.

Acceptable formats: (xxx) xxx-xxxx, xxx-xxx-xxxx, or xxxxxxxxxx

Check if you want to enter secondary address

Not visible to patients. Area code must exist. Acceptable formats: (xxx) xxx-xxxx, xxx-xxx-xxxx, or xxxxxxxxxx

Enter a cell phone number if you do not have a fax number.

We obtain a copy of the patient’s insurance card so you can bill their plan.

Add