1. Terms and Conditions 2. Contact 3. Tax Information 4. Provider Information

Registration Requirements

Please do not use all caps when completing the registration form. Please use proper case when completing the form.

Correct Example Incorrect Example
First Name: John
Last Name: Doe
First Name: JOHN
Last Name: DOE

Before you proceed with your online registration, please be sure to have the following information available:

  • State License
  • National Provider Identifier (NPI)
  • Tax Identification Number (TIN)
  • Malpractice Information (Carrier and Aggregate Amounts)
  • Service Address and Phone Number
  • Supervising Physician Name and License Number (if applicable for Non Physician Medical Practitioner)
  • DHCS Certification License (if applicable)