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 receive an email with instructions and links for our New Provider Documentation for you to review and sign. Once these documents are received, you’ll be all signed up to begin using the billing service!

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

Please verify that you’re human: