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)