Enrollment2018-08-17T18:30:52+00:00

Fill in the information below to enroll in Real-Time Claims Advancement;

Date (required)

Account Manager First Name (required)

Account Manager Last Name (required)

Account Manager Phone


Practice / Hospital

Practice / Hospital Name (required)

Specialty (required)

Office Manager (required)

Chief Financial Officer

Address (required)

Address 2

City (required)

State (required)

Zip (required)

Practice Phone (required)

NPI Number (required)

Fax Number

Fax Number

Email (required)

Practice Website


Physicians

How many Physicians in this Practice


Claims History

How many claims are filed each month? (required)

What is the monthly dollar value of the claims filed? (required)

What Percentage is Insurance? (required)

What Percentage is Medicare? (required)

Bank Name (required)

Bank Address (required)

Bank Address 2

Bank City (required)

Bank State (required)

Bank Zip (required)


Clearing House Information

Clearing House Name

Clearing House Address

Clearing House Address 2

Clearing House City

Clearing House State

Clearing House Zip

Clearing House Phone