CYTEMED NEW ACCOUNT APPLICATION
ONLINE FORM
Url
ACCOUNT INFORMATION
Required fields are marked with an asterisk.
Account Name
*
Practice Phone
*
Practice Fax
*
Address
*
Account Type (specialty)
*
Number of Providers
*
Number of Locations
*
Provider's Name
*
NPI Number
*
Provider License
Provider's Name 2
NPI Number 2
Provider License 2
Provider's Name 3
NPI Number 3
Provider License 3
Provider's Name 4
NPI Number 4
Provider License 4
Provider's Name 5
NPI Number 5
Provider License 5
CONTACT INFORMATION
Practice Contact Name
*
Contact Email
*
Contact Phone
*
PRACTICE INFORMATION
Are you currently providing DME in your practice?
Yes
No
If you are currently providing DME in your practice what forms are you offering?
Writing Prescriptions
Dispensing DME in Your Practice
Approximately what percentage of your patients with insurance have DME coverage that pays you ?
If you are currently dispensing DME in your practice, do you need help with billing or credentialing services?
Yes
No
Scroll to top