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:
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

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Provider:
Credential:*
Tax ID: *
NPI: *

Additional Provider #2
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #3:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #4:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #5:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #6:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #7:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #8:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #9:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #10:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #11:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #12:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #13:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #14:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #15:
Provider:
Credential:*
Tax ID: *
NPI: