Sign up to submit electronically

This Sign-up form allows health care providers and their billing service assignees to obtain eBill connectivity information from Jopari. Jopari’s registration team will review information submitted and arrange contact with you to answer questions and initiate implementation. Do not use this form for inquiries unrelated to eBill registration. Please complete all fields before submitting this form. Thank you.

Company Name:
Type of Company:
Your Name:
Phone:
Email:
Primary billing office information:

Street or PO Box:
City:
State:
ZIP:
Tax ID:
When is the best time to contact you?
Do you currently submit claims / medical bills electronically?	Yes No
What format do you use?
What is the estimated number of workers' compensation bills you send to payers each month?
What is the estimated number of auto medical bills you send to payers each month?
What is the name of your practice management system?
Do you currently use a clearinghouse?	Yes No
What is the name of your clearinghouse?
Message:
Please enter the follwing two words before clicking Submit: