Application for a New Account
Please fill out this form only for yourself. Shared accounts are not allowed.
In order for your account to be activated, you must be able to receive emails from [email protected] Please check with your email administrator to ensure that emails from [email protected] can be received.
Which of the following best describes your company?
 What about read-only radiology offices
NIA does not permit a rendering provider to contractually accept delegation of responsibility for the complete authorization submission from the referring provider. NIA also does not permit a rendering provider to represent itself as a referring provider in order to obtain a complete authorization. These practices could implicate federal or state laws or terms and conditions of a provider contract or benefit plan. Therefore, NIA investigates all situations where this type of activity is suspected or reported. If NIA determines that a rendering provider is representing itself as a referring provider, that provider may be subject to termination from the NIA network.
New Account User Information
Your Direct Report
Unless you are the owner or CEO of your company, the user's name/email must be different than the supervisor's name/email.
Affiliated Facilities
If you have problems, please contact us at [email protected].
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