*Required fields
* Federal Tax Identifier :
* Business Name :
Providers
Please enter the NPI under which your practice bills claims
*
Add Electronic Fund Transfer Role to this Entity.(?)
Authorized Business Contact
* First Name: * Last Name:
* Phone Number:
()- Ext.
* Fax Number:
()-
* Email:
* Confirm Email:
Business contact same as Blue E administrator
Blue e Administrator
* User ID:(User IDs must be 6-8 letters.)
* First Name: * Last Name:
* Phone Number:
()- Ext.
* Fax Number:
()-
* Email:
* Confirm Email:
Terms and Conditions
* I accept these terms and conditions
Authorized Signatory
* First Name: * Last Name:
Title: