Submit a request

To see additional request options, please select "Sign in." If you do not have an account, click on the "Sign in" button and select "Sign up" to create an account.

Please choose a request type below

Your email address

How is this impacting your business?

Subject

Please provide specific details so that we may provide faster support.

Partner Billing Category

Invoice Number(optional)

Invoice number for Credit Request

Which product do you need assistance with?

NPI(optional)

Please enter 9 digits for your NPI number

Account Username(optional)

Practice Username or Name of Affiliate(optional)

If you are not an EPCS Affiliate please enter Practice Username. If you are an EPCS Affiliate, please enter Name of Affiliate (Name of EPCS Organization)

Requested Amount(optional)

Amount for Credit Request

Reason for Credit(optional)

Reason for credit

Other Reason(optional)

Please enter reason for Other

Quote Number(optional)

Please provide Quote number for Provider Renewing Notification

Attachments(optional)

Add file or drop files here

Submit a request

To see additional request options, please select "Sign in." If you do not have an account, click on the "Sign in" button and select "Sign up" to create an account.

Partner Registration Management (DFR)