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PROVIDER REGISTRATION

This form will register you for access to the new benefits verifier site. Upon submitting this form your registration goes to Fox/Everett for approval. The approval process usually takes one to two business days to complete. An email will be sent to the designated contact once your registration has been approved.

* Payer ID Help
* Tax ID Help
* Provider Name Help
* Contact Name Help
* Contact Phone Help
* Address1 Help
Address2 Help
* City Help
* State Help
* Zip Code Help
* EMAIL Help
* Login Name (Tax ID) Help
* Desired Password Help
* Confirm Password Help
* indicates a required field

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