Independent Medical Systems - Online

PROVIDER SIGN-UP

Thank you for your interest in becoming a part of the Independent Medical Systems team.

Members: Please use this form to nominate a provider you would like us to contact for joining the IMS Network.

Providers: Please use this form if you would like more information about how your practice/facility can join the IMS network.

Once submitted our provider relations department will contact the provider. If you have any questions please contact the provider relations department at (800) 853-7003.
Provider Information
Practice/Facility Name:
Provider First Name:
Provider Last Name:
Tax Id: NPI:
Address:
City: State Zip Code:
Contact:
Phone: Fax:
Email:
Select Provider type and specialties. (you can use the CTRL key to select multiple specialties)
Physician:
Ancillary:  
Hospital:  
Enter a message or comments for the provider relations department.
Comments:
Note: If you are filling this form out on behalf of someone other than yourself please specify your name and contact information in the comments field


NOTE: All fields are required.

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