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Create User AccountCreate User Account

Details
Information

Required items are marked with an asterisk (*).

Name:
*First Name:
Middle Name:
*Last Name:
*Email:
*Username:
  • Must be at least 6 characters and no more than 25 characters.
  • Cannot contain 'admin' or 'administrator'.
  • Cannot contain a social security number.
*Password:
  • Must be at least 6 characters and no more than 25 characters.
  • Cannot contain 'password', '123456', '654321' or contain the username.
Confirm by entering again:
Provider Name or Facility Name:
Address:
Street Address:
*City:
*State/Province:
*Postal Code:
Phone Number(s):
*Primary Phone:
*Group Code:
  • Enter the group code that you received in the Provider Enrollment Training Notification.
  • Example: PROV
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