Please complete this form to kick off the process to add the Availity Advanced integrated clearinghouse to Nightingale Notes for your agency.

    Do You Have an Availity Account Already?

    If You Already Have an Availity Account Enter the Account ID

    Please enter the date you would like to start billing through Availity.

    Tax ID (required)

    NPI (required)

    Organization Name (required)

    Phone (required)

    Address Line 1 (required)

    City (required)

    State (required)

    Zip (required)

    Point of Contact First Name (required)

    Point of Contact Last Name (required)

    Point of Contact Email (required)