Lactation Billing Sign-Up Form - Lactation Practice

Lactation Practice Billing

Thank you for your interest in billing with Lactation Practice!

Please complete the following form. After completing the form, you will be directed to a page with links to download our New Provider Documentation for you to review and sign. Please email these documents to [email protected]. Once these documents are received and reviewed, you'll be emailed with confirmation that your account is created. We'll send you all the information you need to contact your biller and get started using our service. Please note that we manually create your account to make sure that we're set up for your individual needs. It may take one or two business days to receive your confirmation email from us. If you have any questions along the way, please don't hesitate to email [email protected].

Thank you! We look forward to working with you.

Warmly,
Renee and Melissa

Billing Sign Up Form

Name:*

First

Last

Credentials:*

Business Name:

E-mail:*

Phone:*

Area Code

Phone Number

Fax:

Area Code

Phone Number

Website:

Address:*

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

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