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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.

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

Office Information

9-digit Tax ID:^*

Office/location name:^*

Address 1:^*

Address 2:

City:^*

State:^*

Zip code:^*

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?

Step 2: Contact Information for User Requesting Access to GlobalLink:

First name:^*

Last name:^*

Contact phone number:^*

Email address: ^*

List of physicians that user may access in GlobalLink:^*

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