Provider Portal Registration

Use the form below to setup your Admin account. This is page 1 of 2 for creating your account. After you complete the form, click "Continue" to proceed to the next page.

Only one Administrator per facility may register for the Portal.  If an Admin has already registered for your facility please contact them to request a User account be created.

TIP: Each account must have a unique e-mail address.

Having trouble? Read our FAQ

Provider Admin User Registration

Please type a username using at least 6 alpha/numeric characters.
Password must be at least 8 characters and must include at least one upper case letter, one lower case letter, one special character, and one numeric digit.
Create Password  
Confirm Password  
E-mail Address  
Confirm E-mail Address  
Security Question 
Answers are case-sensitive.
Security Answer