Client Registration

Client Registration Form

Date

MonthDayYear

Client/Account Information

Business Name*

Legal Business Name as Listed with IRS*

Street Address*

Street Address Line 2*

City*

State*

Zip Code*

Business Phone Number

Mailing/Billing Address*

Same as above

Street Address

Street Address Line 2

City

State

Zip code

Contact Information

Main Contact Person*

Main Contact Phone Number*

Main Contact Alternate Phone Number*

Main Contact E-mail Address*

Billing/Accounting Contact Person*

Billing/Accounting Contact Phone Number*

Billing/Accounting Contact E-mail Address*

example@example.com

Name of Business Owner*

Important Numbers Needed for Billing and Contracting

Tax ID #*

NPI #*

State License #*

Owner SSN*

Owner DOB*

Name of Authorized User for Medicare*

Do You Have A CLIA #?*

NoYes

CLIA #*

Do You Have A Medicare PTAN #?*

NoYes

Mass Vaccination PTAN #*

DME PTAN #*

Portal Access

Do You Have An Optum Pay Portal Account?*

NoYes

Optum Pay Portal - Username and Password

Do You Have An Availity Portal Account?*

NoYes

Availity Portal - Username and Password

Pharmacist Information

Pharmacist Name*

Pharmacist License #*

Pharmacist NPI #*

Upload copies of W-9, Voided Check, IRS EIN Confirmation Letter, CLIA Certificate, Medicare Mass Vaccination PTAN Confirmation, Pharmacy License, & Pharmacist License, Copy of Owners Driver's License*

Browse Files