EZ1500 — Register

Practice/Office Name *

Enter your practice or office name.

Email Address *

Enter a valid email address.

Confirm Email *

Email addresses do not match.

We emailed a 6-digit code to your email address

Didn't get it? Send a new code

First Name *

Your first name is required.

Last Name *

Your last name is required.

Office Phone *

11 digits, starting with 1

11-digit office phone required.

Mobile Phone *

Your verification code is texted here

11-digit mobile number required.

We texted a 6-digit code to your mobile

Didn't get it? Send a new code

Billing Name *

Billing office name is required.

Billing Address 1 *

Billing address is required.

Billing Address 2

City *

City is required.

State *

State is required.

ZIP *

ZIP is required.

Billing Phone *

11-digit billing phone required.

Billing NPI *

10-digit group NPI

A 10-digit NPI is required.

Provider First Name *

Provider first name is required.

Middle Initial

Provider Last Name *

Provider last name is required.

Provider Full Name *

As it appears on the NY WCB authorization

Provider full name is required.

Provider NPI *

A 10-digit NPI is required.

Billing Tax ID *

Tax ID is required.

Tax ID Type *

Choose EIN or SSN.

NY License # *

If unknown, enter first 6 of NPI

NY state license number is required.

NY WCB Authorization # *

If unknown, enter XX

WCB authorization number is required.

NY WCB Rating Code *

If unknown, enter XX

WCB rating code is required.

Type of bills to be submitted

Current method of billing

Anticipated monthly volume

Interested in additional services

Any questions?

✓

Registration complete

Your account will be active in 2–3 business days. We'll email and text you as soon as it's ready.