Web Registration Code Request Form

Welcome to Payspan and thank you for requesting registration information to receive electronic payment. You will receive an email confirming your submission and we will contact you within 24-48 hours with additional registration information.

This information is intended solely for the claims payment related data. If you are searching for information to obtain Quality Program information please click the following link: Request Registration Code (Quality).

*Select 'Other' if the payer name is not listed and add the name to the 'Registration Code Request Comments' field.