2Klean Claims ANSI conversion module
Easy to Use ANSI Direct Electronic Claims Software

2Klean Claims ANSI All Payor Direct Module Registration Form

Single Physician Practice       Multi-Physician Practice       Billing Service
Customer Information:
Customer Name:   
Primary Contact First Name:           Last Name:   
Customer Tax-ID:   
Street Address:   
City:           State:           Zip Code:   
Telephone:           Fax:   
Email:          
Billing Software:          
Would you like to transmit your commercial claims electronically through THIN?:    Yes    No
2K Medical Account manager:   

Please select which Carriers and States you wish to send electronic claims to (excluding commercial carriers).
Carrier Name Select State
Medicare
Medicaid
BCBS
Blue Cross
Blue Shield