Office Information
*Practice Name:  Prime Clinical: 
*Street Address 1:      Street Address 2: 
*City:  *State / Zip: 
*Phone:  Fax: 
*Tax ID:  NPI: 
*Contact Name:  Promotional Code: 
User ID
Please select your User ID for iCompEDI™. This will be your login credential to identify yourself to WorkCompEDI and allow you access to the iCompEDI™ web portal.
 
*User ID: 
Email Address
Please provide a valid email address. This email account will be the location where you will receive correspondences about your iCompEDI™ account, as well as any temporary passwords should you lose your login credentials.
 
*Email: 
Administrative Details
 
File Type: 
 
Please indicate the current practice management system being used.
*Practice Management System: 
   Version: 
 
I am a participating member of: 
 
Please list your current group health clearinghouse vendor for private/group health billing. 
How many workcomp and auto bills do you process per month? 
How are your medical records stored? 
What is your Electronic Health Records (EHR)?  Other: 
Services
Please check all services that apply.
Clearinghouse
Data Dimensions will charge you the rate of sixty-five cents ($0.65) for the delivery of your bill & corresponding notes to electronic route.
Data Dimensions will charge you the rate of one dollar thirty-three cents ($1.33) for the delivery of your bill & corresponding notes to print & mail route.
Proof-of-Service (POS) Add On Service
Data Dimensions will charge you the rate of ten cents ($0.10) per POS added to each transaction.
Direct-to-Mail (DTM) Service
Data Dimensions will charge you the rate of one dollar twelve cents ($1.12) per DTM transaction (includes POS & IntelligentMail Services) up to ten (10) pages.
Each additional page is billed at four cents ($0.04) per page.