ASSERTUS Identity Proofing Form | ASSERTUS On-Line

General Proofing

Account Name
Provider Full Name *
Home Address
DirecciónApartamento, piso, edificio (opcional)CiudadEstado / provincia / regiónCódigo 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
Address
DirecciónApartamento, piso, edificio (opcional)CiudadEstado / provincia / regiónCódigo postalPaís

Verification

Please enter any two digits *Example: 12
Esta caja es para protección contra el spam - por favor déjalo en blanco:

Social Media Auto Publish Powered By : XYZScripts.com