New Account Request

1. Enter the following Practice Information.
 
 
 
 
 


2. Enter Admin Account Information.
 
 
 
   
   


Instructions

Practice Name is the Operating name and/or name used with general public.

Group Practice TIN is the Billing/Operating TIN for the group practice.

Group Practice NPI or LTSS is the NPI or LTSS for the group practice.

Billing Demographics are the current billing address with city, state, and zip.

User Name is the Account ID that will be used for accessing the portal.

First/Last Name is the First/last name of the individual requesting an account.

Email is the  Email address for password resets and portal alerts/notifications.