Local Phone: 801-262-0200
Toll Free In Utah: 800-432-5743
***Please complete, sign and submit. Then call (801-262-0200 ) to make a credit card payment.***
SCAN AND E-MAIL TO PIE STAFF AND THEN CALL TO MAKE CREDIT CARD PAYMENT
Please note any changes in Mailing Address, Telephone including Cell, e-mail address
In order to submit the form you are required to answer every question below. If the questions are not applicable to your practice enter NA.