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Check on a Charge


How it Works

About Us

Privacy Policy Security

Member Registration

Organization Registration


User's Guide

Authorization & Agreement Form


Group Practice Registration: Step 1

Identifying Information
Name of Group Practice:
Street Address:
Primary Phone:  Ext:
Secondary Phone:  Ext:
Group Practice Information
Tax I.D. Number:
Profession Represented:
Primary Contact:
Primary Contact's Phone:  Ext:
Primary Contact E-mail:
Bank Account Information
Bank Name:
Bank Street Address:
Bank City:
Bank State:
Bank Zip:
Bank Phone:  Ext:
Checking Account Number:
Bank Routing Number:
Robot Check
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By checking this box and registering with, you are indicating that you have read and accepted our Member Agreement. This is a binding contract between you and and it contains important provisions regarding, among other things, responsibilities, indemnities, limitations on liability and restricted and prohibited uses of our service. You will not be able to use our services unless you agree to this Member Agreement (Links will open new browser window.) I further authorize to debit my bank account for the annual membership fee. Click on the agreement statement below to complete the registration.
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