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Tissue-Based Allografts XCelliStem®

ActiGraft UltraMIST®XSONX®

Ocular Membranes

VictoryGraft

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CAMPS

Tissue-Based Allografts XCelliStem®ActiGraft UltraMIST®XSONX®

Ocular Membranes

VictoryGraft

Surgical OneCare

Compliance & Education

Careers

Login to OneCare Sign Up Now

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CLINIC PROFILE

EMAIL: OPERATIONS@MDBIOLOGIX.HEALTH

PREFERRED SALES REP

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Preferred Sales Rep Name:

FACILITY INFORMATION

Legal Practice Name:

Practice NPI:

Practice Name / DBA:

Practice PTAN:

Practice TAX ID:

PRACTICE LOCATIONS

PRACTICE LOCATION

Street Address:

City:

State:

Zip:

2ND PRACTICE LOCATION

Street Address:

City:

State:

Zip:

Adds Location 3, 4, 5 (one at a time).

OFFICE CONTACTS

Practice Owner

First Name

Last Name

Phone

Fax

Email

Insurance Eligibility Contact

First Name

Last Name

Phone

Fax

Email

Orders & Logistics Contact

First Name

Last Name

Phone

Fax

Email

Accounts Payable / Invoices Contact

First Name

Last Name

Phone

Fax

Email

PROVIDER INFORMATION

Physician 1

First Name:

Last Name:

Individual NPI:

Medicare PTAN:

Provider Credentials:

DPMMDDONPPA

Physician 2

First Name:

Last Name:

Individual NPI:

Medicare PTAN:

Provider Credentials:

DPMMDDONPPA

Physician 3

First Name:

Last Name:

Individual NPI:

Medicare PTAN:

Provider Credentials:

DPMMDDONPPA

Physician 4

First Name:

Last Name:

Individual NPI:

Medicare PTAN:

Provider Credentials:

DPMMDDONPPA

Physician 5

First Name:

Last Name:

Individual NPI:

Medicare PTAN:

Provider Credentials:

DPMMDDONPPA

Adds Provider 6–10 (one at a time).

EMR / EHR / PAYOR PORTALS

EMR / EHR

URL:

Username:

Password:

Billing Portal

URL:

Username:

Password:

CMS MAC Portal

URL:

Username:

Password:

INSURANCE PORTAL ACCESS

Medicare

URL:

Username:

Password:

State Medicaid

URL:

Username:

Password:

EMR

URL:

Username:

Password:

Other

URL:

Username:

Password:

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Address

1750 Briercroft Ct. Suite 228, Carrollton, TX 75006

info@mdbiologix.health

FDA Registered Tissue Bank Intermediary