This form is for online submissions only.

All fields marked with a red asterisk (*) are required to submit the form.

Practice Registration

Obstetric Services are provided at this practice site *	Yes No
If yes, average number of new obstetric patients enrolled at this site each month *
OB Practice Name *
Street Address *
City *
Zip *
Phone Number *
Primary Fax Number *
This practice site is interested in on-line submission of PRA data *	Yes No
This practice site is currently capable of on-line submission of PRA data *	Yes No
NPI Number
County *	-Select County- Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren
Select MCO(s) *	Aetna Better Health Amerigroup Commercial Insurance Only Does not accept MCOs Horizon NJ Health Self/Pay Uninsured UnitedHealthcare Community WellCare
Are you independent or are you managed by a larger healthcare system or practice group?	Independent Managed
Healthcare System or Practice Group Information System or Group Name Division or Department Address Additional Address City, State Zip ,    System or Group Phone System or Group Fax