NEW LABS CLIENT ONLINE SET UP FORM

Thank you for choosing Revenue Management Corporation! Our first step to a successful partnership is completing the New Labs Client Online Set Up Form. This should only take a few minutes and to help make this a little easier prepare to provide Tax ID, Group PTAN Number, and Charge Master with CPT codes that are currently being supplied for billing.

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Client Name

Tax ID

GROUP NPI

Medicare PTAN Number

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address for Payments if different from above.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Office Phone

(###)

###

####

Cell Phone

(###)

###

####

Office Fax

Email Address

Password

Create a new unique password

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