Provider Enrollment Form
  • FAQ
  •   (*) = required fields
9/2/2010


Owner of Account/Practice Name:*
*Please Note: If this is a billing service, please enroll as a billing service. You may enter provider information below.

Office Information
Mailing Address:
Street Address:*
City:* State:* Zip:*
Contact Information:(individual actually submitting claims)
First Name:* Last Name:*
Telephone:* ( ) - Facsimile: ( ) -
Email:* Title:*
Type Of Practice:*
Billing Service Solo Practice Group Practice
Billing Information
Billing Address: Check if same as mailing address
Street Address:*
City:* State:* Zip:*
Billing contact information: Check if same as contact information above
First Name:* Last Name:*
Telephone:* ( ) - Facsimile: ( ) -
Email:*
Provider/Group Information:

*Please Note: If you are a solo provider/practice, you should enter the provider as the Billing Provider AND Individual Provider. Once you are done filling out the information, click Add.

Group Providers
Name of Billing
 Provider/Group:*
Tax ID:*
Group NPI #:*
Specialty:*


Individual Providers*
First Name:*
Last Name:*
Tax ID:*
Individual NPI:*
Speciality:*
System Information*

*Please tell us how you would like to submit your claims. Check ALL that apply: (must select at least one)

Undecided
Office Ally's Practice Mate
Office Ally's Electronic Health Records System
Office Ally's Online Claim Entry Tool
Forms Used:CMS 1500    UB-04    ADA    
We will be using another billing software (please include your software information below)
Software / Version:
Credit Card Processing Utility
Yes, I am interested in Office Ally integrated credit card processing. Click here for more info...
 Best Time to contact:  Best Contact Method: Phone Email     Promo Code: 

Special Instruction / Alternate Contact
Office Ally Representative

*Please select your Office Ally representative. (If you do not know who your Office Ally representative is please select OTHER).*

Laurie Kirkland EDI Seminar Jose Rivas Robert Simm
Steven Mitchell Jeremiah McMillan Megan Charette Chad Williams
Natalie Goodwin Carl Dowell Kandi Jackson Stuart Forden
Other

How did you hear about us? Check ALL that apply: (must choose at least one)

Internet search or other web site
Magazine Advertisement
Tradeshow/Conference
Seminar
Television Commercial
Referral
Other  
OneHealth Port Users

Currently enrolled OneHealth Port users check the box below, and fill in your OneHealth Port User Name.

Are you a OneHealth Port user? No    Yes
OneHealth Port User Name: *This will become your OfficeAlly User Name if available.

In order to receive your new account information quickly, please fill out and fax or e-mail back the
Authorization Packet located on the screen after you click the SUBMIT button below. (If you do not
receive the pop up, please contact our Enrollments department at (866) 575-4120 option 3)

Thank you for choosing Office Ally!