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.
Primary Contact Name

Question Title

* 1. Primary Contact Name

Primary Contact Number

Question Title

* 2. Primary Contact Number

Primary Title / Position

Question Title

* 3. Primary Title / Position

Secondary Contact

Question Title

* 4. Secondary Contact

Secondary Contact Number

Question Title

* 5. Secondary Contact Number

Secondary Contact Title / Position

Question Title

* 6. Secondary Contact Title / Position

Facility Name

Question Title

* 7. Facility Name

NPI (National Provider Number)

Question Title

* 9. NPI (National Provider Number)

Facility Address

Question Title

* 10. Facility Address

Website

Question Title

* 11. Website

Email

Question Title

* 12. Email

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