Saluda Medical

User Contact Name

First

Last

User Contact Email

User Contact Phone

Physicians Office Name

Physicians Office Phone

Physicians Office Fax

Physicians Office Address

City

State/Province

Zip/Postal

Physicians Office Tax ID (TIN)

Physicians Office NPI

Physician Name

Physician Tax ID

Physician NPI

Physician PTAN (Medicare Provider Number)

Facility Name

Facility Address

City

State/Province

Zip/Postal

Facility Phone Number

Facility Fax Number

Facility Tax ID

Facility NPI

Point of Contact to send Business Associate Agreement (BAA) to:

First

Last

Email

Phone

Saluda Sales Representative Name

Date: Onboarding Call Availability (Option 1)

Date: Onboarding Call Availability (Option 2)

Time