Physician Payments - Physician Payments

Physician Payment Details

Physician Contact Information

First Name Please enter First Name

Last Name Please enter Last Name

NPI

Street Address Please enter Street Address

City Please enter City

State

Zip Code (5 digits) Please enter valid Zip Code / Postal Code Invalid Zip Code

Postal Code Please enter valid Zip Code / Postal Code Invalid Postal Code

Primary Phone Number (10 digits) * Please enter a valid Phone Number

Secondary Phone Number Invalid Phone Number

Email Please enter valid Email address

Retype Email * Please enter valid Email address

Email addresses are not matching

Payment Details

To how many hospitals are you applying? Each additional hospital – Discount is applied if you apply at the same time as the first hospital. Single hospital is $350.00 for physician and $250.00 for APP

Physician Fee($): {{PHYAmount.toFixed(2)}} Advance Practice Provider Fee($): {{PHYAppAmount.toFixed(2)}} Other Fee($):
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Total Amount($) Total Amount is required Please enter valid Amount

Please complete the required fields.