USER SELF-REGISTRATION

Please complete all requested information.

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1) SELECT REGISTRATION TYPE:

2) PROVIDER REGISTRATION

Email

PLEASE ENTER THE TAX #'s (EIN's) FOR REQUESTED ACCESS (comma-delimited):

SELECT THE ORGANIZATIONS - TAX# - NPI BELOW FOR REQUESTED ACCESS:

2) MEMBER REGISTRATION

Email

Member ID

DOB (mm/dd/yyyy)

Zip Code

3) PERSONAL INFORMATION

Last: (Required)

First: (Required)

Middle:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Go paperless for EOBs

4) LOGIN SETTINGS

Username Use Email	Password	Password Strength	Confirm Password

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PRIVACY STATEMENT
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