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GP_Registration
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Personal Information
(
required field)
User Type(s)
Individual & Member
Provider
First Name
Last Name
Date of Birth(mm/dd/yyyy):
Member Identifier/Policy Number
User Type(s)
Individual & Member
Provider
First/Last Name or Institution Name is required.
First Name
Last Name
Or
Provider Group / Institution Name
National Provider ID or Provider Government ID is required.
National Provider ID
Or
Provider Government ID
Payee Address
User Type(s)
Individual & Member
Provider
First Name
Last Name
Email Address (example: jsmith@abc.com)
Phone Number
Job Title
Company Authorization
SBS - Production
User Type(s)
Individual & Member
Provider
First Name
Last Name
Date of Birth(mm/dd/yyyy):
Government Identifier
Agent Number
User Type(s)
Individual & Member
Provider
Agency Name
Government Identifier
Agency Number
User Type(s)
Individual & Member
Provider
First Name
Last Name
Email Address (example: jsmith@abc.com)
Phone Number
Job Title
Company Authorization
SBS - Production
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