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

Address 1    

Address 2    

City                                        

State            
           

Zip                

Phone                  

Fax               
                     

Email                 

Challenge Question (Write your own question for password changes)     

Challenge Response (Response to your question for password changes)     
  

User ID (Used to log in)     

Password 
(Used to log in) 


TIN Number    

Authorized By  



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..