Eligibility Verification Free Trial
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(no credit card required)

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Eligibility Verification
Same Or Similar
Free Proof of Concept

Contact Information

In order to better service your account in the event there are issues or problems that need to be discussed, please supply contact information. Ensure your email address is correct so that we can contact you. This email address will be our primary contact source for your account.

First Name*

Last Name*

Email*

Title

Fax (10 digits)

Phone* (10 digits)

Extension

Tax ID, NPI and Facility Type

Your facility’s Tax ID (Employer Identification Number) and NPI Number are required for setting up your trial account and submission to some payers during transaction processing.

IMPORTANT: Please correctly enter the Tax ID and NPI Number to be sent with submissions to payers.

Tax ID*

NPI*

Facility Type*

Business Demographics

Enter information about your business (practice or facility).

Facility / Practice Name*

How did you hear about us?*

Street Address*

City*

State*

Zipcode*

If referred, who referred you?

Name of Practice Management Software*

Please Submit Your Free Trial

Please Read the Terms
and Submit Free Trial

Limited Liability Agreement

This Agreement is confirmation that you may use our data entry Online Verification at no cost for days. This offer is only valid to licensed medical Providers. These Services utilize an Internet-based System. No installation is required.

Your free trial use of the above referenced Services will automatically expire in days after your approval. There is no Financial Obligation and no Credit Card required.

You agree that datalink solutions makes no warranties or representations, whether express or implied, including, without limitation, any implied warranties of merchantability and fitness for a particular purpose with respect to the above referenced services and/or internet-based system and that in no event will datalink solutions be liable to you or to any other party for any loss, including time, money,goodwill and consequential damages which may arise from use of these services and/or system during your free trial use. This offer is subject to approval and may be revoked without notice.

By completing this enrollment, you are agreeing to the above terms and conditions for your -day free trial use of our services above specified and you authorize Datalink to set up an account with our clearinghouse on your behalf in order to initiate your free trial.

I have read and agree to the above terms. *