Provider Complete – Billing Provider Complete - Billing Service Please select one of the following:*I would like to add a new practice for my billing service.I would like to add a provider(s) to an existing practice.Billing Service Name*Contact Name* First Last Contact Phone*Contact Email* Billing Service Tax #:*Connect to:* Client Host Please provide your Vision Username:*Please provide your Vision Email Address:* Group/Practice Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Group Tax ID*Group NPI*Provider Name* First Last Credentials Provider Tax ID*Provider NPI*Services Requested:* (Select all that apply)* Claims, ERA & Real Time (Provider Inquiry) Professional Claims (1500 CMS) Institutional Claims (UB04) EFT Multiple Practices?**If you select Yes for Multiple Practices, please complete a new form for each Practice (unique Tax ID).*YesNoMultiple Databases?*YesNoDo you wish to add another provider?* Yes No 2nd Provider Name* First Last Credentials Provider Tax ID*Provider NPI*Do you wish to add another provider?* Yes No 3rd Provider Name* First Last Credentials Provider Tax ID*Provider NPI*Do you wish to add another provider?* Yes No 4th Provider Name* First Last Credentials Provider Tax ID*Provider NPI*Do you wish to add another provider?* Yes No 5th Provider Name* First Last Credentials Provider Tax ID*Provider NPI*
