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Name
Email Address
Phone Number
Company Name
Company Mailing Address
Company Billing Information
Forwarding Email for Completed Identity Proofings
Number of Physicians for Supervised Remote In-Person Identity Proofing
Subscription Agreement Option 1
- Physicians Direct Pay with Credit Card at Appointment Booking. By selecting this option you accept the terms and conditions of this subscription agreement.
Subscription Agreement Option 2
- Vendor Invoice. By selecting this option you accept the terms and conditions of this subscription agreement.
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****$25.00 MONTHLY SUBSCRIPTION FEE****

Benefits and Features	Direct Pay $31.50 USD	Vendor Invoice $29.95 USD
Supervised Remote In-Person Identity Proofing for electronic prescribing of controlled substance Physician enrollment . NIST 800-63.3a compliant. Surescripts Certified Identity Proofing Vendor Secure HD video-conference w/live Agents Inter-operable for all devices with webcam function Flexible appointment booking available Secure identity attribute verification via Government databases Non KBA/KBV	Yes Yes Yes Yes Yes Yes	Yes Yes Yes Yes Yes Yes