Optimizer® Smart Patient Access Program Enrollment

Optimizer^® Smart Patient Access Program Enrollment

Practice
Practice Name
Practice Phone Number
Practice Fax Number
Practice Facility
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Practice Tax ID*
Practice NPI
Admin Contact
Admin Contact Name*
First Last
Email*
Phone*
Physician Name (1)*
Physician NPI (1)*
Physician Tax ID (1)*
Physician PTAN (1)*
Physician Name (2)
Physician NPI (2)
Physician Tax ID (2)
Physician PTAN (2)
Facility
Facility Name (1)*
Facility Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Facility Phone Number (1)
Facility Tax ID (1)
Facility NPI (1)
Facility Name (2)
Facility Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Facility Phone Number (2)
Facility Tax ID (2)
Facility NPI (2)