Therapy Network of Puerto Rico

Provider Web Portal Request

Section 1: Provider Identification Information

Practice Last Name

First Name (if applicable)

NPI

Tax ID #

Phone

Ext

Fax

Address 1

Address 2

City

State

Zip

Group Provider/Main Email Address

Section 2: Account Owner Information

The Account Owner has ability to create, and responsibility to maintain, additional users under this account. The Account Owner must be a person directly employed by the practice/facility and authorized by the Security Officer (see Section 3 below) to be accountable for managing operational activities of the practice. No external entities or billing agents may be assigned the role of Account Owner.

Last Name

First Name

Title

Phone

Ext

Fax

Email Address

Verify Email Address

Address is the same as the Group Provider

Address 1

Address 2

City

State

Zip

Section 3: Security Officer Information

The Security Officer is the Primary Controlling Authority (PCA) for the account. The Security Officer must be an individual who has signing authority for your practice/facility - a stakeholder who can legally bind your organization, such as an administrator (facility), stakeholder, managing partner or contracted provider with the practice.

Security Officer is the same as the Account Owner

Last Name

First Name

Title

Phone

Ext

Fax

Email Address

Verify Email Address

Address is the same as the Account Owner

Address 1

Address 2

City

State

Zip Code

Notes

Terms & Conditions:

In no event will Therapy Network of Puerto Rico, its suppliers or other third parties mentioned at this site be liable for any damages whatsoever arising out of the use, inability to use, or the results of use in this site, or any websites linked to this site.

I Agree

Enter the code displayed (please notice that is case sensitive)