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Providers

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