Medical Provider – Service Marketplace Signup

Service Request Type ?
Medical Billing
Billing

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

Medical Collection
Collection

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

Medical Billing
Billing

Medical Collection
Collection

Medical Funding

Funding Needed for

$
$
%
%
%
$
$
%
$
$
%
$
$
%
Date/Time for Call Back Time is in PST(Pacific Standard Time)
Medical Funding

Funding Needed for

$
$
%
%
%
$
$
%
$
$
%
$
$
%
Date/Time for Call Back Time is in PST(Pacific Standard Time)

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

*
Office hours
Pick Up Schedule
Reporting Option
Physician (1) Information
Physician (2) Information
Physician (3) Information
Physician (4) Information
Panels Requested
1.
2.
3.
4.
5.
Panels Requested
pm/after
am

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

Anticipated Payor Mix
%
%
Commercial billing method
Pick Up Schedule
After Hours Emergency Contact

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

Transdermal Pain Creams

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

Closed Accounts

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

Medical Legal

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!