It is important to read the following instructions to ensure your enrollment is processed correctly.
- If you are an office wishing to ENROLL FOR THE FIRST TIME, complete the enrollment form “FIRST-TIME Enrollments” and the “ELECTRONIC PATIENT STATEMENTS” enrollment below
- *Note: The Electronic Patient Statement fee per page is $0.63 for the first page, additional pages are $0.12 and NCOA is $0.30 each. *
- If you are an office wishing to ADD A NEW PROVIDER to an existing enrollment that has already been complete, complete the enrollment form “EXISTING Enrollments” below
- If you wish to DEACTIVATE A PROVIDER, complete the enrollment form “DEACTIVATE Provider”