Provider Registration Form
*
= Required
*
Single Provider
Office Manager
*
Provider
Name:
*
Contact Person:
*
Address:
*
City:
*
State:
Alabama
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pensylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
*
Zip Code:
*
Phone Number:
*
E-Mail:
*
Username:
*
Password:
*
Confirm Password:
*
Secret Question 1:
What is your mother's maiden name?
What is the name of your favorite pet?
What is your father's middle name?
What was your high school mascot?
Who was your childhood hero?
*
Secret Answer:
*
Secret Question 2:
What is your favorite pastime?
What make was your first car?
Who was your favorite teacher?
What was the name of your first school?
What is your favorite sport?
*
Secret Answer:
Username Requirements:
Must be 7 characters.
Password Requirements:
Length is 7 characters or greater.
Must include at least 1 numeric digit (0 through 9).
Must include at least 1 special character (for example, !, $, #, @).
*
Tax Identification Numbers (TIN) or National Provider ID (NPI) (Enter all TINs or NPIs related to you). Provider Name is required.
TIN 1:
And
NPI 1:
Provider Name 1:
TIN 2:
And
NPI 2:
Provider Name 2:
TIN 3:
And
NPI 3:
Provider Name 3:
TIN 4:
And
NPI 4:
Provider Name 4:
TIN 5:
And
NPI 5:
Provider Name 5:
TIN 6:
And
NPI 6:
Provider Name 6:
TIN 7:
And
NPI 7:
Provider Name 7:
TIN 8:
And
NPI 8:
Provider Name 8:
TIN 9:
And
NPI 9:
Provider Name 9:
TIN 10:
And
NPI 10:
Provider Name 10:
TIN 11:
And
NPI 11:
Provider Name 11:
TIN 12:
And
NPI 12:
Provider Name 12:
TIN 13:
And
NPI 13:
Provider Name 13:
TIN 14:
And
NPI 14:
Provider Name 14:
TIN 15:
And
NPI 15:
Provider Name 15:
TIN 16:
And
NPI 16:
Provider Name 16:
TIN 17:
And
NPI 17:
Provider Name 17:
TIN 18:
And
NPI 18:
Provider Name 18:
TIN 19:
And
NPI 19:
Provider Name 19:
TIN 20:
And
NPI 20:
Provider Name 20:
TIN 21:
And
NPI 21:
Provider Name 21:
TIN 22:
And
NPI 22:
Provider Name 22:
TIN 23:
And
NPI 23:
Provider Name 23:
TIN 24:
And
NPI 24:
Provider Name 24:
TIN 25:
And
NPI 25:
Provider Name 25:
TIN 26:
And
NPI 26:
Provider Name 26:
TIN 27:
And
NPI 27:
Provider Name 27:
TIN 28:
And
NPI 28:
Provider Name 28:
TIN 29:
And
NPI 29:
Provider Name 29:
TIN 30:
And
NPI 30:
Provider Name 30:
TIN 31:
And
NPI 31:
Provider Name 31:
TIN 32:
And
NPI 32:
Provider Name 32:
TIN 33:
And
NPI 33:
Provider Name 33:
TIN 34:
And
NPI 34:
Provider Name 34:
TIN 35:
And
NPI 35:
Provider Name 35:
TIN 36:
And
NPI 36:
Provider Name 36:
TIN 37:
And
NPI 37:
Provider Name 37:
TIN 38:
And
NPI 38:
Provider Name 38:
TIN 39:
And
NPI 39:
Provider Name 39:
TIN 40:
And
NPI 40:
Provider Name 40:
TIN 41:
And
NPI 41:
Provider Name 41:
TIN 42:
And
NPI 42:
Provider Name 42:
TIN 43:
And
NPI 43:
Provider Name 43:
TIN 44:
And
NPI 44:
Provider Name 44:
TIN 45:
And
NPI 45:
Provider Name 45:
TIN 46:
And
NPI 46:
Provider Name 46:
TIN 47:
And
NPI 47:
Provider Name 47:
TIN 48:
And
NPI 48:
Provider Name 48:
TIN 49:
And
NPI 49:
Provider Name 49:
TIN 50:
And
NPI 50:
Provider Name 50:
TIN 51:
And
NPI 51:
Provider Name 51:
TIN 52:
And
NPI 52:
Provider Name 52:
TIN 53:
And
NPI 53:
Provider Name 53:
TIN 54:
And
NPI 54:
Provider Name 54:
TIN 55:
And
NPI 55:
Provider Name 55:
TIN 56:
And
NPI 56:
Provider Name 56:
TIN 57:
And
NPI 57:
Provider Name 57:
TIN 58:
And
NPI 58:
Provider Name 58:
TIN 59:
And
NPI 59:
Provider Name 59:
TIN 60:
And
NPI 60:
Provider Name 60:
TIN 61:
And
NPI 61:
Provider Name 61:
TIN 62:
And
NPI 62:
Provider Name 62:
TIN 63:
And
NPI 63:
Provider Name 63:
TIN 64:
And
NPI 64:
Provider Name 64:
TIN 65:
And
NPI 65:
Provider Name 65:
TIN 66:
And
NPI 66:
Provider Name 66:
TIN 67:
And
NPI 67:
Provider Name 67:
TIN 68:
And
NPI 68:
Provider Name 68:
TIN 69:
And
NPI 69:
Provider Name 69:
TIN 70:
And
NPI 70:
Provider Name 70:
TIN 71:
And
NPI 71:
Provider Name 71:
TIN 72:
And
NPI 72:
Provider Name 72:
TIN 73:
And
NPI 73:
Provider Name 73:
TIN 74:
And
NPI 74:
Provider Name 74:
TIN 75:
And
NPI 75:
Provider Name 75:
TIN 76:
And
NPI 76:
Provider Name 76:
TIN 77:
And
NPI 77:
Provider Name 77:
TIN 78:
And
NPI 78:
Provider Name 78:
TIN 79:
And
NPI 79:
Provider Name 79:
TIN 80:
And
NPI 80:
Provider Name 80:
TIN 81:
And
NPI 81:
Provider Name 81:
TIN 82:
And
NPI 82:
Provider Name 82:
TIN 83:
And
NPI 83:
Provider Name 83:
TIN 84:
And
NPI 84:
Provider Name 84:
TIN 85:
And
NPI 85:
Provider Name 85:
TIN 86:
And
NPI 86:
Provider Name 86:
TIN 87:
And
NPI 87:
Provider Name 87:
TIN 88:
And
NPI 88:
Provider Name 88:
TIN 89:
And
NPI 89:
Provider Name 89:
TIN 90:
And
NPI 90:
Provider Name 90:
TIN 91:
And
NPI 91:
Provider Name 91:
TIN 92:
And
NPI 92:
Provider Name 92:
TIN 93:
And
NPI 93:
Provider Name 93:
TIN 94:
And
NPI 94:
Provider Name 94:
TIN 95:
And
NPI 95:
Provider Name 95:
TIN 96:
And
NPI 96:
Provider Name 96:
TIN 97:
And
NPI 97:
Provider Name 97:
TIN 98:
And
NPI 98:
Provider Name 98:
TIN 99:
And
NPI 99:
Provider Name 99:
TIN 100:
And
NPI 100:
Provider Name 100:
TIN 101:
And
NPI 101:
Provider Name 101:
TIN 102:
And
NPI 102:
Provider Name 102:
TIN 103:
And
NPI 103:
Provider Name 103:
TIN 104:
And
NPI 104:
Provider Name 104:
TIN 105:
And
NPI 105:
Provider Name 105:
TIN 106:
And
NPI 106:
Provider Name 106:
TIN 107:
And
NPI 107:
Provider Name 107:
TIN 108:
And
NPI 108:
Provider Name 108:
TIN 109:
And
NPI 109:
Provider Name 109:
TIN 110:
And
NPI 110:
Provider Name 110:
TIN 111:
And
NPI 111:
Provider Name 111:
TIN 112:
And
NPI 112:
Provider Name 112:
TIN 113:
And
NPI 113:
Provider Name 113:
TIN 114:
And
NPI 114:
Provider Name 114:
TIN 115:
And
NPI 115:
Provider Name 115:
TIN 116:
And
NPI 116:
Provider Name 116:
TIN 117:
And
NPI 117:
Provider Name 117:
TIN 118:
And
NPI 118:
Provider Name 118:
TIN 119:
And
NPI 119:
Provider Name 119:
TIN 120:
And
NPI 120:
Provider Name 120:
TIN 121:
And
NPI 121:
Provider Name 121:
TIN 122:
And
NPI 122:
Provider Name 122:
TIN 123:
And
NPI 123:
Provider Name 123:
TIN 124:
And
NPI 124:
Provider Name 124:
TIN 125:
And
NPI 125:
Provider Name 125:
TIN 126:
And
NPI 126:
Provider Name 126:
TIN 127:
And
NPI 127:
Provider Name 127:
TIN 128:
And
NPI 128:
Provider Name 128:
TIN 129:
And
NPI 129:
Provider Name 129:
TIN 130:
And
NPI 130:
Provider Name 130:
TIN 131:
And
NPI 131:
Provider Name 131:
TIN 132:
And
NPI 132:
Provider Name 132:
TIN 133:
And
NPI 133:
Provider Name 133:
TIN 134:
And
NPI 134:
Provider Name 134:
TIN 135:
And
NPI 135:
Provider Name 135:
TIN 136:
And
NPI 136:
Provider Name 136:
TIN 137:
And
NPI 137:
Provider Name 137:
TIN 138:
And
NPI 138:
Provider Name 138:
TIN 139:
And
NPI 139:
Provider Name 139:
TIN 140:
And
NPI 140:
Provider Name 140:
TIN 141:
And
NPI 141:
Provider Name 141:
TIN 142:
And
NPI 142:
Provider Name 142:
TIN 143:
And
NPI 143:
Provider Name 143:
TIN 144:
And
NPI 144:
Provider Name 144:
TIN 145:
And
NPI 145:
Provider Name 145:
TIN 146:
And
NPI 146:
Provider Name 146:
TIN 147:
And
NPI 147:
Provider Name 147:
TIN 148:
And
NPI 148:
Provider Name 148:
TIN 149:
And
NPI 149:
Provider Name 149:
TIN 150:
And
NPI 150:
Provider Name 150:
TIN 151:
And
NPI 151:
Provider Name 151:
TIN 152:
And
NPI 152:
Provider Name 152:
TIN 153:
And
NPI 153:
Provider Name 153:
TIN 154:
And
NPI 154:
Provider Name 154:
TIN 155:
And
NPI 155:
Provider Name 155:
TIN 156:
And
NPI 156:
Provider Name 156:
TIN 157:
And
NPI 157:
Provider Name 157:
TIN 158:
And
NPI 158:
Provider Name 158:
TIN 159:
And
NPI 159:
Provider Name 159:
TIN 160:
And
NPI 160:
Provider Name 160:
TIN 161:
And
NPI 161:
Provider Name 161:
TIN 162:
And
NPI 162:
Provider Name 162:
TIN 163:
And
NPI 163:
Provider Name 163:
TIN 164:
And
NPI 164:
Provider Name 164:
TIN 165:
And
NPI 165:
Provider Name 165:
TIN 166:
And
NPI 166:
Provider Name 166:
TIN 167:
And
NPI 167:
Provider Name 167:
TIN 168:
And
NPI 168:
Provider Name 168:
TIN 169:
And
NPI 169:
Provider Name 169:
TIN 170:
And
NPI 170:
Provider Name 170:
TIN 171:
And
NPI 171:
Provider Name 171:
TIN 172:
And
NPI 172:
Provider Name 172:
TIN 173:
And
NPI 173:
Provider Name 173:
TIN 174:
And
NPI 174:
Provider Name 174:
TIN 175:
And
NPI 175:
Provider Name 175:
TIN 176:
And
NPI 176:
Provider Name 176:
TIN 177:
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NPI 177:
Provider Name 177:
TIN 178:
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NPI 178:
Provider Name 178:
TIN 179:
And
NPI 179:
Provider Name 179:
TIN 180:
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NPI 180:
Provider Name 180:
TIN 181:
And
NPI 181:
Provider Name 181:
TIN 182:
And
NPI 182:
Provider Name 182:
TIN 183:
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NPI 183:
Provider Name 183:
TIN 184:
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NPI 184:
Provider Name 184:
TIN 185:
And
NPI 185:
Provider Name 185:
TIN 186:
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NPI 186:
Provider Name 186:
TIN 187:
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NPI 187:
Provider Name 187:
TIN 188:
And
NPI 188:
Provider Name 188:
TIN 189:
And
NPI 189:
Provider Name 189:
TIN 190:
And
NPI 190:
Provider Name 190:
TIN 191:
And
NPI 191:
Provider Name 191:
TIN 192:
And
NPI 192:
Provider Name 192:
TIN 193:
And
NPI 193:
Provider Name 193:
TIN 194:
And
NPI 194:
Provider Name 194:
TIN 195:
And
NPI 195:
Provider Name 195:
TIN 196:
And
NPI 196:
Provider Name 196:
TIN 197:
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NPI 197:
Provider Name 197:
TIN 198:
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NPI 198:
Provider Name 198:
TIN 199:
And
NPI 199:
Provider Name 199:
TIN 200:
And
NPI 200:
Provider Name 200:
TIN 201:
And
NPI 201:
Provider Name 201:
TIN 202:
And
NPI 202:
Provider Name 202:
TIN 203:
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NPI 203:
Provider Name 203:
TIN 204:
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NPI 204:
Provider Name 204:
TIN 205:
And
NPI 205:
Provider Name 205:
TIN 206:
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NPI 206:
Provider Name 206:
TIN 207:
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NPI 207:
Provider Name 207:
TIN 208:
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NPI 208:
Provider Name 208:
TIN 209:
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NPI 209:
Provider Name 209:
TIN 210:
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NPI 210:
Provider Name 210:
TIN 211:
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NPI 211:
Provider Name 211:
TIN 212:
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NPI 212:
Provider Name 212:
TIN 213:
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NPI 213:
Provider Name 213:
TIN 214:
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NPI 214:
Provider Name 214:
TIN 215:
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NPI 215:
Provider Name 215:
TIN 216:
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NPI 216:
Provider Name 216:
TIN 217:
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NPI 217:
Provider Name 217:
TIN 218:
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NPI 218:
Provider Name 218:
TIN 219:
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NPI 219:
Provider Name 219:
TIN 220:
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NPI 220:
Provider Name 220:
TIN 221:
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NPI 221:
Provider Name 221:
TIN 222:
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NPI 222:
Provider Name 222:
TIN 223:
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NPI 223:
Provider Name 223:
TIN 224:
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NPI 224:
Provider Name 224:
TIN 225:
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NPI 225:
Provider Name 225:
TIN 226:
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NPI 226:
Provider Name 226:
TIN 227:
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NPI 227:
Provider Name 227:
TIN 228:
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NPI 228:
Provider Name 228:
TIN 229:
And
NPI 229:
Provider Name 229:
TIN 230:
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NPI 230:
Provider Name 230:
TIN 231:
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NPI 231:
Provider Name 231:
TIN 232:
And
NPI 232:
Provider Name 232:
TIN 233:
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NPI 233:
Provider Name 233:
TIN 234:
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NPI 234:
Provider Name 234:
TIN 235:
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NPI 235:
Provider Name 235:
TIN 236:
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NPI 236:
Provider Name 236:
TIN 237:
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NPI 237:
Provider Name 237:
TIN 238:
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NPI 238:
Provider Name 238:
TIN 239:
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NPI 239:
Provider Name 239:
TIN 240:
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NPI 240:
Provider Name 240:
TIN 241:
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NPI 241:
Provider Name 241:
TIN 242:
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NPI 242:
Provider Name 242:
TIN 243:
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NPI 243:
Provider Name 243:
TIN 244:
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NPI 244:
Provider Name 244:
TIN 245:
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NPI 245:
Provider Name 245:
TIN 246:
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NPI 246:
Provider Name 246:
TIN 247:
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NPI 247:
Provider Name 247:
TIN 248:
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NPI 248:
Provider Name 248:
TIN 249:
And
NPI 249:
Provider Name 249:
TIN 250:
And
NPI 250:
Provider Name 250:
TIN 251:
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NPI 251:
Provider Name 251:
TIN 252:
And
NPI 252:
Provider Name 252:
TIN 253:
And
NPI 253:
Provider Name 253:
TIN 254:
And
NPI 254:
Provider Name 254:
TIN 255:
And
NPI 255:
Provider Name 255:
TIN 256:
And
NPI 256:
Provider Name 256:
TIN 257:
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NPI 257:
Provider Name 257:
TIN 258:
And
NPI 258:
Provider Name 258:
TIN 259:
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NPI 259:
Provider Name 259:
TIN 260:
And
NPI 260:
Provider Name 260:
TIN 261:
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NPI 261:
Provider Name 261:
TIN 262:
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NPI 262:
Provider Name 262:
TIN 263:
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NPI 263:
Provider Name 263:
TIN 264:
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NPI 264:
Provider Name 264:
TIN 265:
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NPI 265:
Provider Name 265:
TIN 266:
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NPI 266:
Provider Name 266:
TIN 267:
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NPI 267:
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TIN 268:
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NPI 268:
Provider Name 268:
TIN 269:
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NPI 269:
Provider Name 269:
TIN 270:
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NPI 270:
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TIN 271:
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NPI 271:
Provider Name 271:
TIN 272:
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NPI 272:
Provider Name 272:
TIN 273:
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NPI 273:
Provider Name 273:
TIN 274:
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NPI 274:
Provider Name 274:
TIN 275:
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NPI 275:
Provider Name 275:
TIN 276:
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NPI 276:
Provider Name 276:
TIN 277:
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NPI 277:
Provider Name 277:
TIN 278:
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NPI 278:
Provider Name 278:
TIN 279:
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NPI 279:
Provider Name 279:
TIN 280:
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NPI 280:
Provider Name 280:
TIN 281:
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NPI 281:
Provider Name 281:
TIN 282:
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NPI 282:
Provider Name 282:
TIN 283:
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NPI 283:
Provider Name 283:
TIN 284:
And
NPI 284:
Provider Name 284:
TIN 285:
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NPI 285:
Provider Name 285:
TIN 286:
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NPI 286:
Provider Name 286:
TIN 287:
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NPI 287:
Provider Name 287:
TIN 288:
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NPI 288:
Provider Name 288:
TIN 289:
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NPI 289:
Provider Name 289:
TIN 290:
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NPI 290:
Provider Name 290:
TIN 291:
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NPI 291:
Provider Name 291:
TIN 292:
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NPI 292:
Provider Name 292:
TIN 293:
And
NPI 293:
Provider Name 293:
TIN 294:
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NPI 294:
Provider Name 294:
TIN 295:
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NPI 295:
Provider Name 295:
TIN 296:
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NPI 296:
Provider Name 296:
TIN 297:
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NPI 297:
Provider Name 297:
TIN 298:
And
NPI 298:
Provider Name 298:
TIN 299:
And
NPI 299:
Provider Name 299:
TIN 300:
And
NPI 300:
Provider Name 300:
TIN 301:
And
NPI 301:
Provider Name 301:
TIN 302:
And
NPI 302:
Provider Name 302:
TIN 303:
And
NPI 303:
Provider Name 303:
TIN 304:
And
NPI 304:
Provider Name 304:
TIN 305:
And
NPI 305:
Provider Name 305:
TIN 306:
And
NPI 306:
Provider Name 306:
TIN 307:
And
NPI 307:
Provider Name 307:
TIN 308:
And
NPI 308:
Provider Name 308:
TIN 309:
And
NPI 309:
Provider Name 309:
TIN 310:
And
NPI 310:
Provider Name 310:
TIN 311:
And
NPI 311:
Provider Name 311:
TIN 312:
And
NPI 312:
Provider Name 312:
TIN 313:
And
NPI 313:
Provider Name 313:
TIN 314:
And
NPI 314:
Provider Name 314:
TIN 315:
And
NPI 315:
Provider Name 315:
TIN 316:
And
NPI 316:
Provider Name 316:
TIN 317:
And
NPI 317:
Provider Name 317:
TIN 318:
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NPI 318:
Provider Name 318:
TIN 319:
And
NPI 319:
Provider Name 319:
TIN 320:
And
NPI 320:
Provider Name 320:
TIN 321:
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NPI 321:
Provider Name 321:
TIN 322:
And
NPI 322:
Provider Name 322:
TIN 323:
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NPI 323:
Provider Name 323:
TIN 324:
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NPI 324:
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TIN 325:
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NPI 325:
Provider Name 325:
TIN 326:
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NPI 326:
Provider Name 326:
TIN 327:
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NPI 327:
Provider Name 327:
TIN 328:
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NPI 328:
Provider Name 328:
TIN 329:
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NPI 329:
Provider Name 329:
TIN 330:
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NPI 330:
Provider Name 330:
TIN 331:
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NPI 331:
Provider Name 331:
TIN 332:
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NPI 332:
Provider Name 332:
TIN 333:
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NPI 333:
Provider Name 333:
TIN 334:
And
NPI 334:
Provider Name 334:
TIN 335:
And
NPI 335:
Provider Name 335:
TIN 336:
And
NPI 336:
Provider Name 336:
TIN 337:
And
NPI 337:
Provider Name 337:
TIN 338:
And
NPI 338:
Provider Name 338:
TIN 339:
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NPI 339:
Provider Name 339:
TIN 340:
And
NPI 340:
Provider Name 340:
TIN 341:
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NPI 341:
Provider Name 341:
TIN 342:
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NPI 342:
Provider Name 342:
TIN 343:
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NPI 343:
Provider Name 343:
TIN 344:
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NPI 344:
Provider Name 344:
TIN 345:
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NPI 345:
Provider Name 345:
TIN 346:
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NPI 346:
Provider Name 346:
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Provider Name 347:
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Provider Name 348:
TIN 349:
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NPI 349:
Provider Name 349:
TIN 350:
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NPI 350:
Provider Name 350:
TIN 351:
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NPI 351:
Provider Name 351:
TIN 352:
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NPI 352:
Provider Name 352:
TIN 353:
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NPI 353:
Provider Name 353:
TIN 354:
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NPI 354:
Provider Name 354:
TIN 355:
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NPI 355:
Provider Name 355:
TIN 356:
And
NPI 356:
Provider Name 356:
TIN 357:
And
NPI 357:
Provider Name 357:
TIN 358:
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NPI 358:
Provider Name 358:
TIN 359:
And
NPI 359:
Provider Name 359:
TIN 360:
And
NPI 360:
Provider Name 360:
TIN 361:
And
NPI 361:
Provider Name 361:
TIN 362:
And
NPI 362:
Provider Name 362:
TIN 363:
And
NPI 363:
Provider Name 363:
TIN 364:
And
NPI 364:
Provider Name 364:
TIN 365:
And
NPI 365:
Provider Name 365:
TIN 366:
And
NPI 366:
Provider Name 366:
TIN 367:
And
NPI 367:
Provider Name 367:
TIN 368:
And
NPI 368:
Provider Name 368:
TIN 369:
And
NPI 369:
Provider Name 369:
TIN 370:
And
NPI 370:
Provider Name 370:
TIN 371:
And
NPI 371:
Provider Name 371:
TIN 372:
And
NPI 372:
Provider Name 372:
TIN 373:
And
NPI 373:
Provider Name 373:
TIN 374:
And
NPI 374:
Provider Name 374:
TIN 375:
And
NPI 375:
Provider Name 375:
TIN 376:
And
NPI 376:
Provider Name 376:
TIN 377:
And
NPI 377:
Provider Name 377:
TIN 378:
And
NPI 378:
Provider Name 378:
TIN 379:
And
NPI 379:
Provider Name 379:
TIN 380:
And
NPI 380:
Provider Name 380:
TIN 381:
And
NPI 381:
Provider Name 381:
TIN 382:
And
NPI 382:
Provider Name 382:
TIN 383:
And
NPI 383:
Provider Name 383:
TIN 384:
And
NPI 384:
Provider Name 384:
TIN 385:
And
NPI 385:
Provider Name 385:
TIN 386:
And
NPI 386:
Provider Name 386:
TIN 387:
And
NPI 387:
Provider Name 387:
TIN 388:
And
NPI 388:
Provider Name 388:
TIN 389:
And
NPI 389:
Provider Name 389:
TIN 390:
And
NPI 390:
Provider Name 390:
TIN 391:
And
NPI 391:
Provider Name 391:
TIN 392:
And
NPI 392:
Provider Name 392:
TIN 393:
And
NPI 393:
Provider Name 393:
TIN 394:
And
NPI 394:
Provider Name 394:
TIN 395:
And
NPI 395:
Provider Name 395:
TIN 396:
And
NPI 396:
Provider Name 396:
TIN 397:
And
NPI 397:
Provider Name 397:
TIN 398:
And
NPI 398:
Provider Name 398:
TIN 399:
And
NPI 399:
Provider Name 399:
TIN 400:
And
NPI 400:
Provider Name 400:
TIN 401:
And
NPI 401:
Provider Name 401:
TIN 402:
And
NPI 402:
Provider Name 402:
TIN 403:
And
NPI 403:
Provider Name 403:
TIN 404:
And
NPI 404:
Provider Name 404:
TIN 405:
And
NPI 405:
Provider Name 405:
TIN 406:
And
NPI 406:
Provider Name 406:
TIN 407:
And
NPI 407:
Provider Name 407:
TIN 408:
And
NPI 408:
Provider Name 408:
TIN 409:
And
NPI 409:
Provider Name 409:
TIN 410:
And
NPI 410:
Provider Name 410:
TIN 411:
And
NPI 411:
Provider Name 411:
TIN 412:
And
NPI 412:
Provider Name 412:
TIN 413:
And
NPI 413:
Provider Name 413:
TIN 414:
And
NPI 414:
Provider Name 414:
TIN 415:
And
NPI 415:
Provider Name 415:
TIN 416:
And
NPI 416:
Provider Name 416:
TIN 417:
And
NPI 417:
Provider Name 417:
TIN 418:
And
NPI 418:
Provider Name 418:
TIN 419:
And
NPI 419:
Provider Name 419:
TIN 420:
And
NPI 420:
Provider Name 420:
TIN 421:
And
NPI 421:
Provider Name 421:
TIN 422:
And
NPI 422:
Provider Name 422:
TIN 423:
And
NPI 423:
Provider Name 423:
TIN 424:
And
NPI 424:
Provider Name 424:
TIN 425:
And
NPI 425:
Provider Name 425:
TIN 426:
And
NPI 426:
Provider Name 426:
TIN 427:
And
NPI 427:
Provider Name 427:
TIN 428:
And
NPI 428:
Provider Name 428:
TIN 429:
And
NPI 429:
Provider Name 429:
TIN 430:
And
NPI 430:
Provider Name 430:
TIN 431:
And
NPI 431:
Provider Name 431:
TIN 432:
And
NPI 432:
Provider Name 432:
TIN 433:
And
NPI 433:
Provider Name 433:
TIN 434:
And
NPI 434:
Provider Name 434:
TIN 435:
And
NPI 435:
Provider Name 435:
TIN 436:
And
NPI 436:
Provider Name 436:
TIN 437:
And
NPI 437:
Provider Name 437:
TIN 438:
And
NPI 438:
Provider Name 438:
TIN 439:
And
NPI 439:
Provider Name 439:
TIN 440:
And
NPI 440:
Provider Name 440:
TIN 441:
And
NPI 441:
Provider Name 441:
TIN 442:
And
NPI 442:
Provider Name 442:
TIN 443:
And
NPI 443:
Provider Name 443:
TIN 444:
And
NPI 444:
Provider Name 444:
TIN 445:
And
NPI 445:
Provider Name 445:
TIN 446:
And
NPI 446:
Provider Name 446:
TIN 447:
And
NPI 447:
Provider Name 447:
TIN 448:
And
NPI 448:
Provider Name 448:
TIN 449:
And
NPI 449:
Provider Name 449:
TIN 450:
And
NPI 450:
Provider Name 450:
TIN 451:
And
NPI 451:
Provider Name 451:
You must read and agree to the terms in the following notice:
MEDICAL PROVIDERS CERTIFICATE OF AUTHORITY
AND
NOTICE OF CONFIDENTIALITY
This Medical Providers Certificate of Authority and Notice of Confidentiality is Authorized and Confirmed, between the Medical Benefit Plan Sponsor, as authorized by the Contract Administrator and the Medical Provider as evidenced by this Certificate of Authority. The Plan Sponsor, through the Contract Administrator, hereby authorizes and grants secured access to the Medical Provider, for the purpose of managing specific information concerning the Plan and Plan Participants as outlined in this Notice of Confidentiality.
The purpose of this authorization is to allow the Medical Provider to facilitate the functions of a caregiver in providing services to the Plan Member and their Dependents. Information obtained from the Plan shall be disclosed and used only for the purpose of treatment, payment, administration and facilitation of providing medical services to the Plan Member and their Dependents and for plan administration or as otherwise permitted by any federal law, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and/or any State laws governing the use and disclosure of health related information.
Reasonable care and safety shall be maintained at all times to safeguard and protect the rights of all Plan Members and their Dependents in the handling of all plan information including medical claims, payments and the transfer and disclosure of personally identifiable health information.
The Medical Provider agrees to keep in strict confidence, all such information obtained through the Plan and to use such information solely for the purpose as stated herein. The Medical Provider agrees that any and all such information is and shall remain the confidential information of the Plan Member and their Dependents and that the information obtained shall not be disclosed to any third party except for the purposes as stated herein.