ASSERTUS Identity Proofing Form | ASSERTUS On-Line

General Proofing

Account Name
Provider Full Name *
Home Address
DirecciónEdificio, Piso, Puerta...CiudadEstado / provincia / regiónPostal / Código postalPaís
Phone
Email

ID Information

Date of Birth
ID Type
ID number
Expiration date
File Upload

Credentials

Medical License
DEA
DM
Facility Representative Name
Date
Provider Name
Date
Account Representative Name
Date
Comments

Internal Use

Verified
NPPES RegistryPuerto Rico Medical Discipline and licensing boardFinancial Institution Confirmation
Internal Use Comments
Approved by

Verification

Please enter any two digits *Example: 12
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