Jopari eBill Enrollment

This enrollment form allows health care providers and their billing service assignees to request eBill enrollment information from Jopari. Our enrollment 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 enrollment. Please complete all fields before submitting this form.For more information, help with enrollment, or enrollment questions, please call 1-800-630-3060 from 8:00 AM to 8:00 PM ET to speak with a Jopari enrollment specialist; or send us an email message to: support@jopari.com.Thank you.

First Name*
Last Name*
Your Email*
Enter Email Confirm Email
Your Phone*
Company Name*
Website
Primary Billing Contact*
Primary Billing Phone*
Street Address*
Address 2
City*
State*
ZIP Code*
Tax I.D. (no dashes please)*
Type of Submitter*
What format do you use?*
What is the estimated number of workers' compensation bills you send to payers each month?*
What is the name of your practice management system?*
What is the estimated number of auto medical bills you send to payers each month?*
What is the name of your clearing house?*
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