BottomLine Medical, Inc Services

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Thank you for your interest in BottomLine Medical, Inc. To submit a New Client Application Form for billing purposes, simply fill in the online form below, or click here to download a printable (pdf format) New Client Application Form, fill it out, and fax it to us at (704) 527-0928.

New Account Information
Clinic Name (required)
Clinic NCPDP# (required)
Address 1
Address 2
City
State
Zip Code
Phone #
Fax #
Contact Name
Contact Phone #
Contact Email
Federal Tax ID (E.I.N.)

Doctor Name	DEA Number	State License Number

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BottomLine Medical, Inc. | P.O. Box 12214, Charlotte, NC 28220
toll free phone: (888) 527-0919 | fax: (704) 527-0928 | email: info@bottomlinemedical.com