Application For Practice

Please fill in all fields

For questions or issues, call us at 678-905-9566 or email

- Every field is required. A voided check for the business is also required.

- If the Type of Ownership = Sole Proprietor or Other, then the Principal Owner’s SSN, home address, and DOB is required.

- If the practice has more than one location, the applicant is required to list the details on the additional locations after the main.

- If the practice has more than one location and individual location billing is selected, a voided check must be uploaded for each location.


Business Information

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