Get Started

Step 1: Complete the AMBS enrollment form

* Indicates required field

Legal Business Name *

DBA Name (if applicable) *

Tax ID / FEIN *

NPI (Business) *

Email 1 *

Email 2 *

Web address *

Business Phone: *

Mobile Phone: *

Physical Address: *

Line 1

Line 2

City

State

Zip Code

Country

Mailing Address: *

Line 1

Line 2

City

State

Zip Code

Country

Provider 1

Last Name, Title *

First Name *

Middle *

Individual NPI *

Specialty *

Medical License Number *

Medicare Group Number *

Medicare Individual Number *

Medicaid Group Number *

Medicaid Individual Number *

Provider 2

Last Name, Title *

First Name *

Middle Name *

Individual NPI *

Specialty *

Medical License Number *

Medicare Group Number *

MEDICARE INDIVIDUAL NUMBER *

Medicaid Group Number *

Medicaid Individual Number *

Provider 3

Last Name, Title *

First Name *

Middle *

Individual NPI *

Specialty *

Medical License Number *

Medicare Group Number *

MEDICARE INDIVIDUAL NUMBER *

Medicaid Group Number *

Medicaid Individual Number *

Other Insurance Name & Number *

Submit

step 2: Enroll with Vital Monkey

Vital Monkey

Step 3: Enroll with Credit Card Service

Credit Card Enrollment

Step 4: Sign and return Service Agreement

Provided via email

Get Started

Step 1: Complete the AMBS enrollment form

Provider 1

Provider 2

Provider 3

step 2: Enroll with Vital Monkey

Step 3: Enroll with Credit Card Service

Step 4: Sign and return Service Agreement

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