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*WebsitePrimary Billing Contact*Primary Billing Phone*Street Address*Address 2City*State*Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code*Tax I.D. (no dashes please)*Type of Submitter*Please Select OneAncillary Medical ServicesBilling Agent / ServiceClearing HouseHealthcare ProviderHospitalPPO/MCO/MPN/MCN/HCO/PPN/HCNPBM/PharmacyOtherWhat format do you use?*Please Select OneADA 2006 FORMASC X12 5010 A1 Health Care Claim: Professional (837)ASC X12 5010 A2 Health Care Claim: Institutional (837)ASC X12 5010 A2 Health Care Claim: Dental (837)CMS 1500 IMAGE FILEDENTAL (ADA 2012)NCPDP D.0NCPDP UCF/WC FormPAPER NON-STANDARD FORMPROPRIETARY FORMATUB04 IMAGE FILEUCF FORMWEB FORMWhat 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?*MessageCAPTCHA