PROMED HEALTHCARE FTP REQUEST FORM
INSTRUCTIONS
Fill out this form to generate a faxable document ( document example). Click on the Generate Fax button at the bottom of the page Print the generated document (when printing use "Landscape" mode for better result) For HIPAA compliance have your contracted provider/group read the fine prints and sign the document Fax the document to the number on the generated fax document
PROVIDER INFORMATION
Enter the provider/group information in the fields below. All fields with "*" are required. If a field is not applicable please use "N/A" in the field.
IPA : * PROVIDER / GROUP : * TAX ID : * ADDRESS : * CITY :  * STATE: Select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming * ZIP: * PHONE : * FAX : * CONTACT NAME : * CONTACT EMAIL : *

FTP USER INFORMATION
Enter your staff information below, we will create an FTP account for each user and contact you to give you their login and password. All fields with "*" are required. If a field is not applicable please use "N/A" in the field.
FIRST NAME * LAST NAME * TITLE * EMAIL * PHONE * FAX * 1 2 3 4 5 6 7 8 9
CLICK GENERATE FAX ONLY ONCE! (Duplicate submissions might result in delaying your request)