Provider Complete Enrollment for Billing Services (5+ providers) Fields marked with an asterisk (*) are required. Billing Service Name:* Contact Name: Contact Phone:* Contact Email:* Billing Service Tax #:* Connect to :* ClientHost Please provide your Vision Username:* Please provider your Vision email address:* Group / Provider Name: * Street Address: City: State: ---ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYDCFMGUMHMPPWPRVI Zip Code: Group Tax ID:* Group NPI:* Services Requested:* (Select all that apply) Claims, ERA & Real Time (Provider Inquiry)Professional Claims (1500 CMS)Institutional Claims (UB04)EFT Multiple Databases?: YesNo ------------------------ Provider: Credential:* ---CNMCRNADCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: * Additional Provider #2 Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #3: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #4: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #5: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #6: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #7: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #8: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #9: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #10: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #11: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #12: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #13: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #14: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: Additional Provider #15: Provider: Credential:* ---CNMDCDODPMDPTLCSWMDMSWNPODPAPhDPsyDPTRN Tax ID: * NPI: