New Account Form

First Name(Required)

Last Name(Required)

Email(Required)

Sales Representative Same as Individual Completing Form

I am sales representative filling out this form on behalf of the customer.

Sales Representative First Name(Required)

Sales Representative Last Name(Required)

Sales Representative Email(Required)

Agency Name(Required)

CUSTOMER INFORMATION

Account Name(Required)

Primary Customer Type(Required)

Secondary Customer Type

Primary Purchase Type(Required)

Account NPI #

Provider First Name(Required)

Provider Last Name(Required)

Provider Title(Required)

Provider NPI #(Required)

Primary Specialty(Required)

Secondary Specialty

Use the NPI Registry lookup here.

Shipping Attention Line(Required)

Shipping Street Address(Required)

Shipping City(Required)

Shipping State(Required)

Shipping Zip Code(Required)

Billing Address same as Shipping Address

Billing Attention Line(Required)

Billing Street(Required)

Billing City(Required)

Billing State(Required)

Billing Zip Code(Required)

ACCOUNT CONTACTS

Main Contact First Name(Required)

Main Contact Last Name(Required)

Main Contact Email(Required)

Main Contact Phone Number(Required)

Main Contact Fax Number

Please be aware that the main contact listed on this account will be enrolled in our customer portal. This includes having access to account-based data, such as patient and financial information.

Accounts Payable Email(Required)

Send transactions via email

Send transactions via print

AP Contact same as Main Contact

Accounts Payable Contact First Name(Required)

Accounts Payable Contact Last Name(Required)

Accounts Payable Phone Number(Required)

Sales Tax Exemption Form

Max. file size: 128 MB.

Tax ID #(Required)

Authorized Signer same as Main Contact

Authorized Signer First Name(Required)

Authorized Signer Last Name(Required)

Authorized Signer Email(Required)

CLAIMS AND REIMBURSEMENT

Medical Biller Location(Required)

Claims Reimbursement Contact First Name(Required)

Claims Reimbursement Contact Last Name(Required)

Claims Reimbursement Email(Required)

Claims Reimbursement Phone(Required)

OTHER INFORMATION

Other Information

Please select if the customer is a member of Vizient / Southern Strategic Partners.

Please select if customer is a member of Vizient / Southern Strategic Partners.

GPO Member ID

IDN Member ID

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Comments

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