­

Medical Provider – Service Marketplace Signup

Service Request Type ?
Medical Billing
Billing

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

Medical Collection
Collection

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

Medical Funding

Funding Needed for

$
$
%
%
%
$
%
$
$
%
$
$
%
Date/Time for Call Back Time is in PST(Pacific Standard Time)

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

Diagnostics Tests Needed
Reserve 5 days before start

Billing Method
Anticipated Payor Mix

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

Transdermal Pain Creams

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

Closed Accounts

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!

Medical Legal

DO NOT HAVE REP/PROMO CODE? CALL 800.447.3186 TO GET ONE!