Provider Sign-up Request

"*" indicates required fields

Provider Options

Provider Options*

Option 1: Enabled provider - agree to a 2.5% mediBucks settlement discount

Option 2: Preferred provider - agree to a 10% mediBucks settlement discount

Group Name

Main Contact Person Name

Practice Name

Main Contact Person Surname

Practice Number

Main Contact Phone

Existing Practice MGMT System & Version

Main Contact Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bank Name

Account Number

Branch Number

Type of Account

Acknowledgements

I am aware that this is a request only and give my consent that the information supplied be used to pre-populate information onto the mediBucks provider agreement for my final approval and signature.

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This field is for validation purposes and should be left unchanged.