PROVIDER REGISTER FORM


To provide you with immediate access, first we verify your Provider office; then we collect information about you; finally we ask you to set up your security access.

If an Office Account Administrator has already been established in your office, please contact that person to set up your account rather then attempting to register on-line. To start registration, please enter your Provider's Tin, a Participant SSN or Alt Id and a Claim Number previously processed by us for this Patient. We use these items to verify the Provider in our System.


Information above will be submitted via a secure connection to protect your confidentiality.