If you need to setup your provider account, complete the form below:

Personal Information Please fill in your personal information.  
First Name
Last Name
Phone Number
   
Provider Identification The Security and Privacy of health care information is our highest priority. Please fill in the following fields so that we may correctly identify your account.  
Provider/Clinic Name
Federal Tax ID
(do not include hyphen)
 
Address Line 1
Address Line 2
City
State
Zip Code
     
Account Creation Please enter your email address and a password that is 8-15 characters in length. Passwords must contain a combination of upper and lower case letters and numbers.
Email Address
Select a Password  
Retype Password
     
   

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