MEDICAL BILLING SOFTWARE
MEDICAL BILLING SOFTWARE
ALLMED SERVICES USA INC
1-800-858-5768
SET-UP FORM
THE ALLMED SUPERIOR SYSTEM
REQUIRED SET-UP INFORMATION WHEN PURCHASING

Fax to: (352) 742-1631) or Email to: allmedusa@fastmail.us
or Mail to: PO Box 1130, Tavares, FL 32778



Practice Name:______________________________________________________________________________________

Practice Address_____________________________________________________________________________________

City:________________________________________________State:_____________________Zip:__________-_______

Practice Phone:___________________________________________Fax::_______________________________________

Back Line Phone:__________________________________________Email:______________________________________

Practice NPI#:_______________________________________________________________________________________

Practice TIN #:___________________________________________________Specialty Code:______________________
                                                                                                                                      (Type of Practice)
Taxomonmy Code:___________________________________________________________________________________

Physician's Name_________________________________________________________Title:_______________________

Physicians' NPI #:____________________________________________________________________________________

CLIA # (isapplicable):__________________________________________________________________________________

Address you receive insurance claim paymentg checks if different than above address.

Payment Address:____________________________________________________________________________________

City:______________________________________State:_______________________Zip:_____________-____________

Contact Person's Name_______________________________________________________________________________


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