Client Set Up Form

NOTE: If you signed up as a RevAssurance Online BETA Tester, we will use the information you provided in the sign up form to create your Client Organization. If you did not provide a company during your BETA sign up and would like to create one now, then proceed below and enter “BETA” for order number. Thank you.

    * = required

    *Order Number (From your receipt.)

    *Email (The email you used to sign up for RevAssurance.)

    *Full Name

    Your Company Position

    Your Company's Information

    *Company Name

    *Company Tax ID

    *Company NPI#

    *Company Full Address (Street, City, State, Postal Code)

    *Company Phone

    Company Fax

    Company Website

    NOTE: Please note that the submission forms on this site are not protected by security mechanisms. Therefore, please refrain from including sensitive information and the unsecured transfer of PHI which could constitute a HIPAA violation.

    Before you click "Send", please check each box below to agree to each of the following: