BI Solutions Plus
™
Copay Portal
Create Facility Account
Facility Name
Facility NPI
Facility NCPDP
Facility Address
Facility Address Line 2
Facility City
Facility State
AL
AK
AS
AZ
AR
AA
AE
AP
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Facility Zip
Point of Contact First Name
Point of Contact Last Name
Point of Contact Email
Point of Contact Number
Please provide applicable user list in table format, including First and Last Name, Email, and NCPDP for portal access and submission of claims for Product.
Attach File
* Files must be excel, word, csv, or txt with a maximum size of 5MB each
Submit
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