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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.
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Contact Name
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Contact Phone
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Practice / Group Name
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Billing Provider TINs (Enter multiple TINs including dashes, separated by commas, ##-#######, ###-##-####)
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Address
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City
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State
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Suite
Zip
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Telephone Number
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Front Office Email Address
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Fax Number
IPA PHYSICIANS ONLY
Authorizing Officer
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Email Address
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Allow Submit Claims Online?
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Does User have PIP Account?
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PiP Username
Yes
No
Yes
No
Title
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Authorizing Officer
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Email Address
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Yes
No
Yes
No
Title
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User
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Email Address
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Yes
No
Yes
No
Title
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