Account information
Spaces are allowed; punctuation is not allowed except for periods, hyphens, and underscores.
A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.
1. Contact Information
Your name or the name of the primary responsible contact for your organization. The content of this field is kept private and will not be shown publicly.
Your title or position. The content of this field is kept private and will not be shown publicly.
Your Phone Number. The content of this field is kept private and will not be shown publicly.
The street address where we can contact you. Please include the suite number, mail stop or any other pertinent address information. The content of this field is kept private and will not be shown publicly.
The mailing address city. The content of this field is kept private and will not be shown publicly.
The mailing address state. The content of this field is kept private and will not be shown publicly.
The mailing address zip code. The content of this field is kept private and will not be shown publicly.
2. Provider Information
The name of the Healthcare Provider. The content of this field is kept private and will not be shown publicly.
Please select the option that best describes this healthcare provider. The content of this field is kept private and will not be shown publicly.
Your Arizona health license number. The content of this field is kept private and will not be shown publicly.
Your Social Security Number or Tax Identification Number. The content of this field is kept private and will not be shown publicly.
If you provide services under any DBA, please list them here. The content of this field is kept private and will not be shown publicly.
The street address where the healthcare provider is physically located. The content of this field is kept private and will not be shown publicly.
The physical address city. The content of this field is kept private and will not be shown publicly.
(Arizona Only) The physical address county.
The physical address state. The content of this field is kept private and will not be shown publicly.
The physical address zip code. The content of this field is kept private and will not be shown publicly.
3. Service Information
How frequently do you intend to file liens? The content of this field is kept private and will not be shown publicly.
Would you like somone at SWMS to contact you regarding Level 1 services or other services we offer? The content of this field is kept private and will not be shown publicly.
How did you hear about Southwest Medical Services, Inc?
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By registering an account on this website you are entering into this contract with Southwest Medical Services, Inc™ ("SWMS™"). Click here to read the complete terms and conditions.

If you have any questions, please call (602) 424-0229 or email questions to info@swmsinc.com.