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Fee Amount

Note: * indicates required fields

*Credentialing Process:

Reappointment
Initial Applicant

*Practitioner Type:

*Fee Type:

*Specialty:

Amount Due:

Practitioner

Note: * indicates required fields

MD ID #/AHP ID # (if known):

*First Name:

Middle Name:

*Last Name:

*Address:

Address(cont.):

*City:

*State:

*Zip:

*Primary Contact Number:

*Email Address:

Billing

Note: * indicates required fields

Same as practitioner?

*First Name:

*Last Name:

*Address:

Address (cont.):

*City:

*State:

*Zip:

*Payment Option:

Mastercard, Visa, Amex, Discover

Version:1.5.2