ACNC Understanding and Enrolling in EFT Registration - Tuesday, October 11, 2022: 12:00 - 1:00 p.m.

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* 1. Your organization or practice/group name

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* 2. Your Name (First and Last)

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* 3. Title

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* 4. Practice Type

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* 5. Specialty

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* 6. Your organization or practice/group NPI number

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* 7. Your organization or practice/group tax identification number (TIN)

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* 8. Contact Information

Email Address *

Phone Number

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* 9. Is your organization contracted with AmeriHealth Caritas North Carolina?

Yes

No

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* 10. If not, would you like your Regional Account Executive to contact you about joining our network?

Yes

No