Agency Registration
Agency Name:
Affiliation:
Street Address
City: County: State
Zipcode
Country
Email Address
Provider ID
voice phone number() -
fax() -
Password
Type of Agency
Profit or Non Profit
Community Based, Hospital Based, or Nursing Home Based
Single Agency or Part of a Chain of Agencies
Programs
Home Health Care
Hospice
Home Care Aide support care
Home Care Aide personal care
Home Infusion therapy
Durable Medical Equipment
Home Dentistry
Medical Supplies
Respiratory
Staffing Agency
Rehabilitation
Respite Care
Ventilator
Wound Care
Specialties
AIDS
Alzheimers
Case Management:
Diabetes
Enterostomal therapy
Maternal
Multiple Languages
Neonatal Care
Nutrition
Oncology
Oral Medicine
Pediatrics
Psychiatry
Other
Certification CHAP , JCAHO
Billing Information
Acceptable Reimbursements Medicare , Medicaid, Private Pay
Method of payment to Digital Med?
Account number
Expiration Date