Bracco Diagnostics | Third Party Billing Form

Third Party Billing Account Request Form

For questions or requests regarding Third Party Billing, please email thirdparty@bracco.com

Requestor Name*:		Requestor Phone:
Requestor Email*:
Third Party Billing Code:
Carrier*:
	FedEx has informed Bracco, orders required to ship small parcel via FedEx must be processed by 2pm EST to ensure same day shipping with FEDEX Third Party Billing account.
	If selecting FedEx, click here to acknowledge.

Special Instructions:	Inside Delivery Inside Pickup Lift Gate Other

Please note: This address must be the bill to address where the bills for the account number are sent. Any error in this address will cause the carrier to reject the use of the account number by Bracco. This will result in removal from the 3rd party billing program.


Address*:
City*:		State:*
Zip*:
	Please enter affected customer numbers below:*