RadMD.com

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 RadMDSupport@evolent.com. Please check with your email administrator to ensure that emails from RadMDSupport@evolent.com can be received.

Which of the following best describes your company?
What about read-only radiology offices

NIA only allows rendering providers to initiate authorization requests. NIA does not permit a rendering provider to represent itself as a referring provider as this could violate federal &/or state laws. NIA investigate all situations where this is suspected or reported. If NIA determines that a rendering provider is representing itself as a referring provider, their ability to initiate authorization could be revoked and NIA may report the rendering provider to the appropriate oversight agency.

New Account User Information
Choose a Username:
First Name:	Last Name:
Phone:	Fax:
Email:	Confirm Email:
Company Name:	Job Title:
Address Line 1:	Address Line 2:
City:	State:
Zip:

Your Supervisor
Unless you are the owner or CEO of your company, the user's name/email must be different than the supervisor's name/email.
First Name:	Last Name:
Phone:	Email:

Affiliated Facilities
Facility Tax ID #:
Your Tax IDs:

If you have problems, please contact us at RadMDSupport@evolent.com.