User Online Account Credentials

To sign up as a new user and request access to the services on the Provider Portal, fill in the information below.

The username cannot contain special characters, such as, <>, #, |, &, ~, ?, (), {}, %, or *.
The password must be at least eight (8) characters and contain one (1) character of each of the following four (4) characteristics:
- Upper Case (A-Z)
- Lower Case (a-z)
- Numerals (0-9)
- Special characters (for example: !, $, #, or %)
Special characters can be created by holding down the shift key plus the number key that shows your special character at the same time.
The password cannot contain the Username.

When changing your password:

The password cannot be one of previous twenty-four (24) passwords
The password cannot be reset more than one time per day.

You will be automatically logged in upon successful sign up.

* Red asterisk indicates required

User Name*

Password*

Confirm Password*

First Name*

Middle Name/Initial

Last Name*

Suffix

Date of Birth (mm/dd/yyyy)

Social Security Number
(i.e. 123-45-6789)

Contact Information

Phone Information

Type*

Phone Number(999)999-9999*

Extension

Email Address (example@abc.com)*

Select Security questions for which you know the answer. If you forget your password, you will be asked to answer these questions to recover your password.

First Security question*

Answer*

Second Security question*

Answer*

Contact your local office if you have any questions.

Type*

Phone Number(999)999-9999*

Extension

Type*

Phone Number(999)999-9999*

Extension