The National Association of Claims Management Centers

Name

Company

Address

City State Zip

E-mail Address (necessary for delivery of newsletter)
Telephone Number & Area Code

NOTE: Print this page and send with check payable to EMBN to:

Electronic Medical Billing Network of America, Inc.
51 Eton Court, Bedminster, New Jersey 07921
Phone 908-470-4100 FAX 908-654-6443
Email: merl@medicalbillingnetwork.com

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Major charge cards accepted
For faster service, use your credit card. Fill out the additional
information below, print this page and fax to: 908-470-4233
Upon authorization of your card, we will e-mail your first issue immediately.

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American Express Master Card Visa

Card Number

Date of Expiration

Name on Card

NOTE: Print this page and fax with above credit card info to: 908-470-4233

Electronic Medical Billing Network of America, Inc.
51 Eton Court, Bedminster, New Jersey 07921
Phone 908-470-4100 FAX 908-470-4233
Email: merl@medicalbillingnetwork.com
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