Provider Registration
     
◊=Required field
 
 Provider Name:◊
 

 Specialty:◊
 

 Street Address:◊
 

 E-mail:◊
 
 
 City:◊             State:◊  Zip:◊
   

 Phone:◊            Fax:
 

 Notes:
 
 

        
   
 

If you are a medical practitioner and would like to join the AMR Reviewer Network, please complete the medical provider registration form. Please note that if you are an MD or a DO, you must be Board-Certified in order to join.
If you wish to join us without completing this form, please e-mail your request to reviewer@admere.com or call 800.726.1207.



Please print and sign the provider agreement document.
The signed agreement should be faxed to 310-295-1141
 Provider Agreement
 
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