Please fill out this online form and submit the information so we can send you login credentials and keep you updated on changes in reporting.

Please contact us if any questions:
903-593-4722
support@rac-g.org

Thank you.

* 1. Primary Contact Name

* 2. Primary Contact Number

* 3. Primary Title / Position

* 4. Secondary Contact

* 5. Secondary Contact Number

* 6. Secondary Contact Title / Position

* 7. Facility Name

* 9. NPI (National Provider Number)

* 10. Facility Address

* 11. Website

* 12. Email

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