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HealthCare Facility Details
:
Organization Name
*
Tax ID
*
Email
*
Phone Number
*
-
Street Address
*
Country
*
State
*
City
*
ZIP / Postal Code
*
-
5-digit ZIP
4-digit ZIP
Participating Physician Details
:
Note: You can add additional providers after completing your registration
Last Name
*
First Name
*
Salutation
*
Degree
*
Fax
NPI Number
*
Mobile Number
-
Email
Date of Birth
Gender
*
Male
Female
This Information is Requried
Specialization
*
This Information is Requried
Account Administrator Details (same as Company bank Account)
:
First Name
*
Last Name
*
Date of Birth
*
Salutation
*
Age
*
Gender
*
Male
Female
Email
*
Mobile Number
*
-
SSN Last 4 (required for linking Bank Account)
*
Country
*
State
*
City
*
ZIP / Postal Code
*
-
5-digit ZIP
4-digit ZIP
Country
*
Account Number
*
Routing Number
*
Account Name
*
Login Credentials
:
Username
*
Confirm Username
*
Password
*
Confirm Password
*
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:
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