Twilight Billing - Create An Account

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Please use the form below to create a free Twilight Billing trial account. The trial period for this account is 15 days, during which you will have access to the full version of the program with all features enabled.

After 15 days, if you wish to continue using Twilight Billing please contact our sales representatives through one of the methods listed here, and your account will be reactivated. If you choose to not continue the service, your account will automatically disabled at no further obligation.


Center Information
Center Name:
Owner:
Administrator:
Phone:	( ) -
Address:
City:
State:
Zip:
Email Address: (why do we need this?)

Submitter Code:
Provider Number:
Please note that the submitter code and provider number are not required to create an account, however if you wish to create claims to upload to the Medi-Cal system during your trial period, you will need to complete these fields. If you choose not to enter this information, you will still have full access to all parts of the program. To add this information after you have created your account, please go to the Edit Center Information page within the administration section.

Account Information
Choose a Username:
Choose a Password:
Re-Type Password:

Account Type:	Trial
Duration:	15 Days

Additional Information
How did you hear about us?
	If other, please specify: