Interest in Waystar Clearinghouse Form

If your practice is interested in the Waystar platform for claims submissions, remittances and eligibility.

You can start the process by completing the form below. Please fill out all required sections and submit

Once your form is received the following will take place:
• MEDENT will send your practice a Waystar Connection Authorization form to sign.

• A Waystar representative will reach out to your practice to review their solutions.

MEDENT Account #*

Practice Name*

Contact Name*

Title*

Preferred phone # for call back*

- -


E-Mail Address*


State(s)*


Number of Providers


Monthly Claim Volume


To who's attention should we send the MEDENT Waystar Connection Authorization form?

Signatories Name:*

Signatories Email:*