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 *
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 *
This practice site is currently capable of on-line submission of PRA data *
NPI Number
County *
Select MCO(s) * Aetna Better Health
AmeriGroup
Horizon NJ Health
UnitedHealthcare Community
WellCare
 
Are you independent or are you managed by a larger healthcare system or practice group?