First Name * Use legal first name

Last Name * Use legal last name

Birthday *

Email *

Phone Number *

City *

Zip Code *

Username *

Password *

Company Name * Use Legal Business Name based on RSI (if applicable)

How did you hear about us? *

Choose EIN or SSN * Select Document Type EIN SSN

Instructions: "Enter the EIN or SSN number below depending on the selection above" EIN/SSN No *

Upload EIN/SSN Document *

Required Documents * Select Document Type Business License/Certification Accreditation/Certification Facility Policies and Procedures Healthcare Provider Contracts Healthcare Quality and Performance Data HIPAA Compliance Documentation Emergency Preparedness Plan Facility Contact Information Financial Information Medical Equipment and Technology Instructions: "Please scan the required documents listed above and upload them using the form provided."

Upload Required Document *

Insurance Certificates* Select Document Type General Liability Insurance Workers Compensation Insurance Professional Liability Insurance Instructions: "Please scan the Insurance documents listed above and upload them using the form provided."

Upload Insurance Document *

Important Notes:
• Ensure that all documents are scanned clearly and saved in PDF format.
• Double-check that all required documents are uploaded to avoid delays in the registration process.
• For any technical assistance or inquiries, please contact BetleyHub support at support@betleyhub.com.