Request Access

ORGANIZATIONS WHO SUBMIT FOR MULTIPLE PROVIDERS:
Enroll as a submitter only once. List ALL providers that you submit for at the bottom of this page. If you submit for more than 15 hospitals please contact the THCIC Help Desk at 888-308-4953.

PROVIDERS WHO SUBMIT FOR THEMSELVES:
Enroll your facility as the submitter. List (as the Primary Contact) the person in your facility responsible for submitting claim data.

Submitter Information

Business Name
Street Address 1
Street Address 2
City
State
Zipcode

Primary Contact

Name
Email Address
Phone Number
Fax Number

Alternate Contact

Name
Email Address
Phone Number

Providers

Provider 1

THCIC ID
Provider Name
Provider City

Provider 2

THCIC ID
Provider Name
Provider City

Provider 3

THCIC ID
Provider Name
Provider City

Provider 4

THCIC ID
Provider Name
Provider City

Provider 5

THCIC ID
Provider Name
Provider City

Provider 6

THCIC ID
Provider Name
Provider City

Provider 7

THCIC ID
Provider Name
Provider City

Provider 8

THCIC ID
Provider Name
Provider City

Provider 9

THCIC ID
Provider Name
Provider City

Provider 10

THCIC ID
Provider Name
Provider City

Provider 11

THCIC ID
Provider Name
Provider City

Provider 12

THCIC ID
Provider Name
Provider City

Provider 13

THCIC ID
Provider Name
Provider City

Provider 14

THCIC ID
Provider Name
Provider City

Provider 15

THCIC ID
Provider Name
Provider City