Preferred Partner ProgramMain Practice LocationPractice NamePractice Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Practice PhoneFax PhoneEmail NPI #Tax ID #(must have to pay claims)Contact Person at this locationBest way to contactCoherent Preferred Partner Program - Vendor Authorization FormIf you are interested in opening an account with any of the following vendors, please indicate so with a checkmark in the box. If you already have an account number, please provide us with that information. This is the best way to make sure that you are maximizing your office discounts and getting as much credit towards your dues as possible.Primary Strategic Vendor PartnersAbyde - HIPAA ComplianceChose "Other" if you have an account, please provide acct # Do not need an account Need account ADO Practice Solutions - GPOChose "Other" if you have an account, please provide acct # Do not need an account Need account Best Price Digital - Optical LabChose "Other" if you have an account, please provide acct # Do not need an account Need account Biotissue - Amniotic MembraneChose "Other" if you have an account, please provide acct # Do not need an account Need account BluePay - Card ProcessingChose "Other" if you have an account, please provide acct # Do not need an account Need account Blythe Medical - Amniotic MembraneChose "Other" if you have an account, please provide acct # Do not need an account Need account Compliancy Group - HIPAA ComplianceChose "Other" if you have an account, please provide acct # Do not need an account Need account EyecarePro - Marketing/WebChose "Other" if you have an account, please provide acct # Do not need an account Need account BoxSeeChose "Other" if you have an account, please provide acct # Do not need an account Need Account Lunovus - SupplementsChose "Other" if you have an account, please provide acct # Do not need an account Need Account MODOChose "Other" if you have an account, please provide acct # Do not need an account Need Account Modern Optical - FramesChose "Other" if you have an account, please provide acct # Do not need an account Need Account Paubox - Secure EmailChose "Other" if you have an account, please provide acct # Do not need an account Need Account Proof Eyewear - FramesChose "Other" if you have an account, please provide acct # Do not need an account Need Account RevolutionEHR - PM & EHR SoftwareChose "Other" if you have an account, please provide acct # Do not need an account Need Account Walman Optical - Optical Lab & FramesChose "Other" if you have an account, please provide acct # Do not need an account Need Account WestGroupE - FramesChose "Other" if you have an account, please provide acct # Do not need an account Need Account
