Provider Portal Registration Form
Please submit only one use per office.
 
First Name            
                    
Last Name      

Address 1    

Address 2    

City                                        

State             AAAEAKALAPARASAZCACOCTDCDEFLFMGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMPMSMTNCNDNENHNJNMNVNYOHOKORPAPRPWRISCSDTNTXUTVAVIVTWAWVWIWY           

Zip                

Phone                  

Fax               
                     
Email                 

 

Challenge Question (Write your own question for password changes - The Challenge question must be at least 10 characters in length)  

Challenge Response (Response to your question for password changes; answers must have at least 5 alphanumeric characters and cannot be repeated)        
  
 

Challenge Question # 2 (Write your own question for password changes - The Challenge question must be at least 10 characters in length)   

Challenge Response # 2 (Response to your question for password changes; answers must have at least 5 alphanumeric characters and cannot be repeated) 
 

Challenge Question # 3 (Write your own question for password changes - The Challenge question must be at least 10 characters in length)

Challenge Response # 3 (Response to your question for password changes; answers must have at least 5 alphanumeric characters and cannot be repeated) 
 

User ID (Used to log in. User IDs are limited to 16 characters in length)

Password (Used to log in and must be at least 10 characters, containing 1 upper case character, and 1 special character and cannot contain the User ID)


TIN Number    

Authorized By  

 By checking this box you authorize that to the best of your knowledge, the information contained in this form is accurate and reliable.

As a provider of dental/medical procedures, it is your responsibility to ensure that user passwords are changed in the event of staff turnover in order to protect patient’s PHIAs a provider of dental/medical procedures, it is your responsibility to ensure that user passwords are changed in the event of staff turnover in order to protect patient PHI.As a provider of dental/medical procedures, it is your responsibility to ensure that user passwords are changed in the event of staff turnover in order to protect patient PHI. As a provider of dental/medical procedures, it is your responsibility to ensure that user passwords are changed in the event of staff turnover in order to protect patient PHI..