Quality Registration Code Request Form

Welcome to Payspan and thank you for requesting registration information to access Quality related data. You will receive an email confirming your submission and we will contact you within 24-48 hours with additional registration information.

This information is intended solely for the Quality Program participant. If you are searching for information to obtain claims payment related data please click the following link: Request Registration Code (Claims)

Company Type*

Are you a Billing Agency or Clearinghouse? Use the claims form instead.

Provider Tax ID #*

Provider ID # (PIN)

Provider NPI*

Provider or Practice Name*

Comments

Provider Phone Number*

Provider Billing Address*

Provider Billing City*

Provider Billing State*

Provider Billing Zip Code*

Affected Payer*

Requester Name*

Email Address*

Requester SSN (Last 4 digits only)

Requester Drivers License Number

Drivers License State of Issuance