Health services provider
Request for secure web site access

Note: Asterisks [*] indicate required information.

Type of service


If you have more than one office, a separate request form must be completed for each office.

For offices with more than one health services provider, each person who bills under his/her own practice should complete a separate form.

Login ID


Indicate your unique login ID below.

Please enter a valid login ID.

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

Provider information


Please enter the legal name of the individual provider or clinic.

Please enter your operating or practice name.

Please enter a valid phone number for your business.

Please enter a valid fax number for your business.

Business address


Please enter your business address.

Please enter your city.

Please select your province.

Please enter your postal code.

Mailing address


Please enter your business address.

Please enter your city.

Please select your province.

Please enter your postal code.

Payment information


Please enter the name to whom payments should be addressed.

Please enter your business address.

Please enter your city.

Please select your province.

Please enter your postal code.

Contact information


(Person to be contacted regarding online claim submission and/or restricted information.)

Please enter contact's first name.

Please enter contact's last name.

Please enter a valid phone number for contact.

Please enter contact's email address.

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.




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