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ACNC Understanding and Enrolling in EFT Registration - Tuesday, December 6, 2022: 12:00 - 1:00 p.m.
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1.
Your organization or practice/group name
(Required.)
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2.
Your Name (First and Last)
(Required.)
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3.
Title
(Required.)
4.
Practice Type
5.
Specialty
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6.
Your organization or practice/group NPI number
(Required.)
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7.
Your organization or practice/group tax identification number (TIN)
(Required.)
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8.
Contact Information
(Required.)
Email Address
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Phone Number
9.
Is your organization contracted with AmeriHealth Caritas North Carolina?
Yes
No
10.
If not, would you like your Regional Account Executive to contact you about joining our network?
Yes
No
