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Account & Company Details

Account

First Name

Last Name

Security Question

Security Answer

Company

Company Name

Mailing Address 1

Mailing Address 2

City

State/Zip

Phone

Billing Information

Credit Card
Bank Account

We Accept

Card Number

Cardholder's Name

Expiration

Security Code

What is this?

Same as company mailing address

Mailing Address 1

Mailing Address 2

City

State/Zip

Account Type

Checking
Business Checking
Savings

Routing Number

This is the first 9 numbers at the bottom of your check.

Account Number

Name on Account

Bank Name

Overview of Charges & Payment Authorization

Today you will be charged $0. Total includes initial setup fee.

Starting Saturday, September 21, 2019 you will be charged $0 (1 provider x 0.0000) each month for the remainder of the trial period.

Starting Saturday, September 21, 2019 you will be charged $299 (1 provider x 299.0000) each month as long as your account is open.

Your trial will end on Saturday, September 21, 2019.

I agree to the terms and conditions specified in the Terms of Service. Additionally, I authorize payment of any one-time and/or recurring charges outlined in the form above.

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Benchmarks Plus Registration

Benchmarks Plus Registration

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Account & Company Details

Account

Company

Medicare Provider Numbers

Billing Information

Overview of Charges & Payment Authorization

Terms of Use

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