Payer New Account Request

* First Name

* Last Name

* E-mail Address

Job Title

* Company/Agency

* Telephone

Extension

* Mailing Address

Mailing Address 2

* City

State/Province

* Zip/Postal Code

* Country

Please indicate your payer type (check all that apply):

Payer (entity that provides funding for health and human services)

Insurer (entity that contracts to indemnify, via insurance, for delivery of health and human services)

Regulator (entity with oversight authority regarding compliance with laws, regulations, and rules by providers of health and human services)

Please specify your company/agency type:

Government Entity

Private, not for profit

Private, for profit

Publicly traded

Sole proprietor

Other (please describe) Other Description

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