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Medisoft Basic Patient Accounting Registration

MEDICAL PRACTICE

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Legal Business Name
DBA (Doing Business As)
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Corporate Structure

Corporate Structure CORP INC LLC
Phone Phone - ### - ### ####
Fax Fax - ### - ### ####
Email

Confirm Email Address
FEI/EIN Number
Must be 9 digits. Currently Entered: 0 digits.
National Provider Identifier (NPI)
Must be 10 digits. Currently Entered: 0 digits.
Massage Establishment License Number
REFERRING PROVIDERS

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How many referring providers?

How many referring providers? 1 2 3 4 5
① Name of Referring Provider ① Name of Referring Provider First Middle Last
① Referring Provider Credentials
① Referring Provider License Number
① License Certificate
① National Provider ID (NPI)
② Name of Referring Provider ② Name of Referring Provider First Middle Last
② Referring Provider Credentials
② Referring Provider License Number
② License Certificate
② National Provider ID (NPI)
③ Name of Referring Provider ③ Name of Referring Provider First Middle Last
③ Referring Provider Credentials
③ Referring Provider License Number
③ License Certificate
③ National Provider ID (NPI)