DME User Signup

DME Signup

Email (will be your user name)

Password

Full Name

Company Name

Street Address

City

State/Territory

ZIP

Mobile

Office Phone

Fax

EIN (Employer Identification Number - Tax ID assigned to your company by the IRS)

NPI (National Provider Identifier )

Medicare Application Status

Date You Applied for Medicare

PTAN (Provider Transaction Access Number - assigned to you by Medicare upon enrollment)

DME Owner's Date of Birth
(only needed if we are applying to Medicare for you or updating your PTAN)

DME Owner's Social Security Number (only needed if we are applying to Medicare for you or updating your PTAN))

Profile Pic

Document Upload: Please upload copies of relevant documentation (accreditation letter, certificates, etc.)

*** Please Note ***

The billing cycle for your subscription begins once the OR02 Product Category for your DME is approved by BOC. That is the point in which you begin utilizing our Practitioner for your credentialing on a month-to-month basis. We do not wait on your PTAN for Medicare nor your first referral to start the billing cycle for your subscription. Once you are BOC approved, you can start dispensing OR02 Orthopedic Braces through any insurance company that you are actively in-network with.

By checking this box, I certify that I have read the above statement regarding ACFIM's subscription billing policies and affirm that I both understand and will comply with said policies and procedures.