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Provider Digital Signature Signup
This form is to easily get providers set up for resupply and recertification requests!
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* Indicates required question
What is the Providers' NPI
*
Your answer
Next enter their email
and/or
cell phone number
** If the provider would prefer someone else get notified on requests they can set up a reviewer!
What is their Email
Your answer
What is their cell phone number
Your answer
Is this the
Drs
Email or Cell Number?
*
Yes
No
This is for a reviewer
Next
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