Access Form

You can also download this form as a PDF.
Please fill out the form, have it signed by your office physician, and fax or mail to us as indicated at the bottom of page 2.

*required

Contact Name *	Contact Phone *
Practice / Group Name *	Billing Provider TINs (Enter multiple TINs including dashes, separated by commas, ##-#######, ###-##-####) *

Address *

City *

State *

Suite	Zip *
Telephone Number *	Front Office Email Address *
Fax Number

			IPA PHYSICIANS ONLY
Authorizing Officer *	Email Address *	Allow Submit Claims Online? *	Does User have PIP Account? *	PiP Username
		Yes No	Yes No
Title *

Authorizing Officer *	Email Address *	Yes No	Yes No
Title *

User *	Email Address *	Yes No	Yes No
Title *