New Client Creation
Office Name
Specialty
-- select an option --
Internal Medicine
Family Medicine
Pediatrics
Cardiology
Neurology
Psychiatry
General Dentistry
Orthodontics
Oral Surgery
Periodontics
Endodontics
Have you ever submitted electronic medical insurance claims?
Yes
No
Paper Medical Claims Only
MCW Form
Contact Name
Best Email
Attach Redacted EOB (PDF)
Credentialing Form
Practice Name
Contact Information
Doctor Name
Organization NPI
Provider NPI
Practice Manager Name
Practice Manager Contact
Select all billable treatments that apply
Sleep
Surgical
Diagnostic
Submit