Community Physician Portal
To create a new account, please fill out the following form
Information about You
*
First Name:
*
Last Name:
*
Work Email Address:
(this will be used as your username)
*
Password:
*
Password (
verify
):
*
Work Phone:
Extension:
Information about your Group/Office
*
Group Or Provider Name:
*
Group Or Provider NPI/API:
Address:
City:
State:
Zip:
*
Billing Tax ID:
Office Phone Number:
Office Type:
Office Type Comments (
if Other
):
Medical Group
Billing Entity
Provider (Solo)
Hospital
Other
Validate your identity with one of the following:
*Please provide either claim or referral information (not both):
Claim Number:
Claim Service Date:
Claim Total Billed Dollars:
OR
Referral Number:
Referral Start Date:
Referral 1st CPT Code:
Optional:
Validate your identity to access PCP Panel listings
Please provide your PCP Code and PCP NPI that are associated with the TIN you are submitting.
*Note: You can also add a PCP Code to your account after your account has been activated by accessing the Update Account link while logged in.
PCP Code:
PCP NPI:
(
*
Denotes required fields)
Your session will expire in
seconds.
Do you want to extend your session?
