GlobalLink™ Access Request

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GLOBALLINK ACCESS REQUEST

Please complete the form below to request access to GlobalLink™. Note that GlobalLink™ is only available to contracted providers. Please allow 7 business days to process your request.

To request multiple users, please submit a separate form for each user. Alternatively you may contact Provider Relations (globallink.access@globalhealth.com) to request a Bulk User Access Request Form.

9-digit Tax ID: *

Office/location name: *

Address 1: *

Address 2:

City: *

Zip: *

Fax number:

Is your office a billing agency? Only select Yes, if you are a 3rd party billing company or billing agency. *

Yes
No

Is your office the billing and/or administrative location for your facility or provider group? *

Yes
No

What is the number of providers in your office?

Contact Information for User Requesting Access to GlobalLink™

First Name: *

Last Name *

Contact phone number: *

Email: *

List of physicians that user may access in GlobalLink™ *

* Denotes required field.

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