WebForm - Create Account

Select User Type

Select One: I am a...
Email

Your email address is your username. Please use the email address where your invitation to the portal was received. You may change your email address once you have successfully created your account by going to the Account page.

 

Provider Lookup

This is a secure site. We require unique pieces of information in order to match your portal account to your provider account in our administrative system accurately. We will only require this information now at account setup and possibly in the future if your account was to become locked due to failed attempts at login.
 
CHECK BOX IF YOU DO NOT HAVE OR DO NOT KNOW PROVIDER NPI NUMBER
Provider Individual NPI
Provider Last Four SSN (####)
Provider Full SSN (#########)
Provider Date Of Birth (MM/DD/YYYY)
 

Create Password

Password must include all of the following elements:

  • 7
    Minimum Length
  • A/a
    Uppercase/Lowercase
  • 0-9
    Number
  • %
    Special Character
Password
Confirm Password
 

Security Questions

Please pick 3 questions out of the list provided and answer. These questions will be used in the future if you need to reset your password.
Question
Answer
 
Step Four - Question Two
Question
Answer
 
Step Four - Question Three
Question
Answer