Provider Application

1 Business information

2 Professional information

3 Payment information

Business information

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

Area code must exist. Acceptable formats: (xxx) xxx-xxxx, xxx-xxx-xxxx, or xxxxxxxxxx

Check if you want to enter secondary address

Check if you want to receive text messages in addition to email notifications

Not visible to patient. Only sent to pharmacy with electronic prescription



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

Add