Provider Enrollment

I hereby attest that all of the disclosed information is true and accurate. I hereby expressly give authorization to SAP Referral Services, LLC and any of its members to make contact with any party listed on this application, including but not limited to educational institutions, licensing organizations, insurance carriers or any other entity supplied herein. I understand that if any of this information is deemed inaccurate or untruthful, SAP Referral Services, LLC or any of its members may terminate this relationship without notice.

I hereby agree to indemnify, defend and hold harmless SAP Referral Services, LLC, its members and employees against any and all liabilities, loss, damage, claim or cause of action related to any direct or indirect services provided.

By typing your name below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By typing your name below you consent to be legally bound by this Agreement's terms and conditions.