Emdeon Vision for Claim Management Registration

Thank you for your interest in Emdeon Vision for Claim Management. Please provide the following information to help complete your registration (* = required field).

Facility Information

*Facility Name:

*Facility Tax IDs:

*Facility Address Line 1:

Facility Address Line 2:

*City:

*State:

*ZIP Code:

Vendor Name:

Contact Information

A representative will contact the person below to provide a username, password, and assistance with your initial login.

*First Name:

*Last Name:

*Email Address:

*Phone Number:

ext.

Emdeon Vision requires a username and password to access. When registration is complete you will be issued a temporary password and will be required to change it when you first access the system. Please provide your preferred usernames below. NOTE: If both of your choices are already in use, your first choice will be modified to be unique:

*Username First Choice:

*Username Second Choice:

How did you hear about this web site?:

Other: