Electronic Contracting Registration

Form Instructions

Use this form to add or update details about your legal contract signatory.

All notifications relating to provider agreements are made by email. When documents require signature, DocuSign is used. Contractual documents must be reviewed and signed electronically by the person delegated (the legal contract signatory) to receive contractual notifications and sign provider agreements on behalf of contracted physicians or other health care professionals at your practice.

Your details

Please enter your contact information for this request:
First name: Last name:
Email: Phone:
Effective date of change: [mm/dd/yyyy]

Provider or facility contract information
Are you currently signed up for electronic contracting?    
Yes No      
         
Provider Last name: Provider Middle name:  
Provider First name:      
Organization name(s): Doing business as (DBA):  
Provider NPI: Organization or clinic NPI:  
Tax ID: Medicare billing number:  

Legal contract signatory information
Last name: First name:  
Email: Phone:  
We recommend you use an email account dedicated to contracting that remains with the provider instead of an individual’s email account. This will ensure future contractual communications are received regardless of staffing changes.