HealthCare Facility / Provider Registration

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
-

Date of Birth

Gender*
Male Female

Specialization*

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*

2-factor authentication:

Enable 2-factor authentication

Terms And Conditions:

I Accept the for Organization

I Accept the for Users