Provider Registration Form
Provider Name
*
First Name
Last Name
Practice Name / Company Name
*
Website
*
Business Address
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
How many locations does your practice have?
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Email
*
example@example.com
Available Credentials:
NPI Number, License Number, Other
Please upload a photocopy of the license(s) stated above.
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Are you currently utilizing any laboratory testing for TBI?
Estimated total monthly patient volume:
How many PI/LOP patients does your office typically see each month?
Do you work primarily on liens, i.e., do you primarily bill law firms, or are you billing to PIP/Medpay? We only work on liens, not Auto insurance.
Are you interested in Private Labeling?
Yes
Not at this time
Does your practice utilize the Rivermead Post-Concussion Symptoms Questionnaire?
Yes
No
Do you currently perform phlebotomy draws in-office?
Yes, my staff is able to perform phlebotomy
No
Please indicate any additional users for your portal. Please include their full name, email address, and role (provider or company manager).
Note: Each email address must be unique and different from the Provider Email indicated above.
Clear TBI Sales Representative (if applicable)
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