Skip to main content

Providers

Request website access

You need to complete and submit the form below to complete the request.

Request for secure website access

If you have more than one office, complete a separate request form for each office.

Login ID

Indicate your unique login ID below.

Your login ID must contain three to fifteen letters and/or numbers and no spaces or symbols.

Please enter your login ID

Provider information

Please enter your legal name of the individual provider or clinic.
Please enter your operating/practice name.
Please enter a valid phone number.
Please enter a valid fax number.

Business address

Please enter your business address.
Please enter your city/town.
Please select your province.
Please enter your postal code.

Mailing address

Please enter your mailing address.
Please enter your city/town.
Please select your province.
Please enter your postal code.

Payment information

Please enter your name
Please enter your payment address.
Please enter your payment city/town.
Please select your payment province.
Please enter your postal code.

Contact information

Please enter contact first name
Please enter contact last name
Please enter contact initial
Please enter a valid contact phone number.
Please enter a valid contact email address.
Please enter a valid contact fax number.

Authorization

In order to fill out this form, you must be an authorized representative of the above-mentioned health services provider.

Please enter authorized representative's name