Web Registration Code Request Form

Welcome to Payspan and thank you for requesting registration information to receive electronic payment. 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 claims payment related data. If you are searching for information to obtain Quality Program information please click the following link: Request Registration Code (Quality).

Company Type

Provider Tax ID #*

Provider ID # (PIN)

Provider NPI

Provider or Practice Name*

3rd Party Company Name

Provider Phone Number*

3rd Party Phone Number

Email Address*

Registration Code Request Comments

Affected Payer*

*Select 'Other' if the payer name is not listed and add the name to the 'Registration Code Request Comments' field.

Provider Billing Address*

Provider Billing City*

Provider Billing State*

Provider Billing Zip Code*