AntsZtm Registration Form

Please provide the following information:

Company Name for Registration:

Billing Service?

Yes  No

Group Name:

Specialty :

Federal Tax ID #:

Mail To Address:
City, State, Zip:
Contact Phone #:		Fax#:
Contact Name(s):

Complete this section (one form for EACH provider)

Provider Full Name:		Credentials:
SS# (required):

Medicare UPIN #:

ø"þ" Each Module Requested:

	Medicare PIN #:		Group #:
	Medicaid PIN #:		Group #:
	Blue Shield PIN #:		Group #:

CLIA #:

State License #:

øAuto Posting:

Database Name:

Machine Name:

Payment Code:

Adj Code:

 

Auto Posting Path To Lytec Data:

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Software To Systems, Inc. (Internal Use)

Date:

State Receiver ID:

State Sender Code:

Submitter Number:

Lytec Version:

Service Pack:

Password:

Account Number: