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ACXSS Enrollment Form

Practice Name *

Name of Authorized Doctor *

Specialty *

Authorized Business Contact *

Street Address *

Address 2

City *

State *

Zip Code *

Email *

Phone Number *

# of Locations *

# of Providers

McKesson (Medical Supplies). Bill To ACCT #:

McKesson (Medical Supplies). Ship To ACCT #(s):

Henry Schein (Medical Supplies). Bill To ACCT #:

Henry Schein (Medical Supplies) Ship To. ACCT #(s):

Office Depot (Office Supplies). Bill To ACCT #:

Office Depot (Office Supplies). Ship To ACCT #(s):

Amazon Business. Bill To ACCT #:

Amazon Business. Ship To ACCT #(s):

VaxServe (Vaccine Distributor). Bill To ACCT #:

VaxServe (Vaccine Distributor). Ship To ACCT #(s):

Medico-Mart (Vaccine Distributor). Bill To ACCT #:

Medico-Mart (Vaccine Distributor). Ship To ACCT #(s):

By submitting your application you agree to the Participation Agreement terms

Yes *

Please verify your request. *

To complete your ACXSS enrollment, you will need to confirm your email after clicking "Join Now."

Your enrollment is not complete until you click the link to confirm that email.

The confirmation email will come from:
isilverberg@acxss.com

If you do not see the email:
Check your Spam, Promotions, or Junk folder
Or search your inbox for: “ILH”