Sale Rep Name *

Start Date

dd-MMM-yyyy
Web portal creation date

Company Name *

Location

i.e. Tampa, FL

Street Address *

Address Line 2

Postal / Zip Code *

Company Phone *

Company Fax

Company Website

Main Contact Phone *

Main Contact Email *

Credentials *

NPI *

Doctor Name *

Standard Criteria?

Service Types

MCT

MCT Fee For Service

AMI bills for Technical only – 93226 – Account bills for Hook-up 93225 and Professional Component 93227
AMI bills for Technical – 93226 and Hook-up – 93225 and Account Bills for Professional – 93227
AMI bills for Global – 93224

Extended Holter Fee For Service

Billing Contact Phone

Par Level

Comments

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