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Health Care Provider Practice Information

All fields marked with * are required.
 

For new providers working with the team at Healthcare Billing360, please fill out these simple intake forms. The following form is secure and encrypted. Questions? Contact Us.

 

Click on the button below to be directed to the New Client form. 
 

 

For clients who prefer to fill out the form and fax it to us manually, you can download it here and fax it to (330) 319-8130.

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