Access Form

Please complete the Online Registration form and press Submit, you will have the option to print this form so you are able to sign and fax it to finalize the registration process.

*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 *