Change Healthcare Provider Complete Enrollment for Billing Services

Use the following form if you are enrolling for Provider Complete for the first time.

*If you are already enrolled in Provider Complete, please return to the Enrollments page and select the correct form to add an additional provider.*

* Please complete one lead for each practice. All forms must be submitted at the same time. Please note failure to complete the correct form will result in your enrollment being delayed.*

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:

Check the types of e-mail notifications you want sent to this address: