New Account Setup

Number of Providers:

Number of Mid-Levels

Multiple Locations?

YesNo

If Yes, How Many Locations?

Other Programs

Practice Name

Address

City

State

Zip Code

Practitioner Name

Individual NPI#

Organizational NPI#

First Name

Last Name

Title

Phone

Fax

Email

Full Name

Billing Phone

Billing Email

Billing Address

Billing City

Billing State

Billing Zip Code

Payment Method

ACH PaymentCheck

Name of Person Who Will Be Receiving Monthly Statements

Statement Recipient's Phone

Fax

Email

Name of Person Whol Will Be Receiving Claimpay's Request For Missing Billing Info

Missing Billing Phone

Fax

Email

Attach Your Documents

Files may either be a PDF or scanned image format (JPG, PNG, etc.)