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Jennifer Ward
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New Account Setup
Patient Health First
New Account Setup
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Number of Providers:
Multiple Locations?
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If Yes, How Many Locations?
PROGRAMS
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Point Of Care Dispensing
Rapid Diagnostic Testing
503B Injections & Creams
Medical Supplies
Other Programs
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BILLING INFORMATION
Full Name
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ATTACH THE FOLLOWING DOCUMENTS WHEN SUBMITTING THIS FORM:
State Licenses
DEA Licenses
Additional New Account Setup Forms (503B)
DocRx Credit Card Authorization Form
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