Practice Enrollment Form

To submit an enrollment request, please fill in as much detail as possible about your practice and doctors. All fields marked with an asterisk (*) below are required. All information provided will be stored in your browser session and will be automatically deleted when your session expires ( after there has been no action in at least 15 minutes). Channel-Markers Medical uses the information you submit on this form to process your enrollment request. By clicking on the “Submit Enrollment” button below, you agree that the information you provide will be governed by our site Privacy Policy.

Practice Information

Practice Name *

Name Layout Fax

NPI *

Tax ID

Phone *

Fax Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

User Information

Name *

First

Last

Middle Name

Email *

Prescriber

NPI *

Tax ID

Name *

First

Last

Middle

Ref Taxonomy *

Phone *

Fax

SLN

DEA

PTAN

Email *

After clicking "Submit Enrollment" one of our representatives will reach out to your office in order to verify your account with you.