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

Address *

City *

State * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY

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 *

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

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User *	Email Address *	Yes No	Yes No
Title *

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