1. Enter Email Address:*
(Enter Group/Vendor or Practitioner's e-mail address. The same e-mail address cannot be repeated for another Group/Vendor or Practitioner).
Email Address:
2. Enter Name:*
First Name:
Last Name:
3. Practice/Facility Information*
Select if you are a Professional Provider AND/OR a Facility/Institutional Provider.
Professional Provider - 837P & CMS -1500 billers
Facility/Institutional Provider -837I & UB04 billers
Both Professional Provider and Facility/Institutional Provider
4. Enter Vendor/Group's Name or Practitioner's Name and Specialty Type
Practice/Facility/Vendor Name:
5. Enter: the 10-digit National Provider ID (NPI) and 9-digit Blue Shield Number (If applicable)
NPI #:
Blue Shield # (Optional):