Paxera Referring Physician Portal Account Intake Form

Practice Information

Please enter information for the Practice here.

Practice Name*

Address of Practice Location*

Phone Number of Practice Location*

Fax Number at Practice Location

Practice Administrator Name*

Practice Administrator Phone*

Practice Administrator Email*

Authorizing Provider's Name

Only required if the user does not have an NPI number.

Please enter user information below.

User Type*

Select

User First Name*

User Last Name*

Suffix

Select or enter value

Credentials

Select or enter value

Specialty

Address (if different from Practice)

User Phone Number*

User Email*

NPI

Market Region*

Please select the market(s) you need access to.

Select or enter value

Default Region*

If you selected more than one market region, what is the default region you need access to?

Select or enter value

Month and Date of Birth (xx/xx)*

Last four of SSN*

Please provide a 4-digit pin.*

Which method do you prefer for Multi-Factor Authentication (MFA)?*

Select