Provider Account Request

Please fill in the fields below to create your account.

Account Information

Required Desired Username

Required Password

Password must be Minimum length of 12 characters, Contain Upper and Lower Case Letters, Contain at least 1 Number, Contain at least 1 Letter, Contain at least 1 Special Character

Required Verify Password

Required Email Address

Required Verify Email Address

Time Zone Required

User Information

Required First Name

Required Last Name

Required Phone Number

Required Address

Required City

Required State

Required Zip Code

Provider Information

Participating With Required

Tax ID / National Provider ID

Required

Press the enter key between ID's

Required Full Facility Name

For account creation help, please contact support at support.information@healthsmart.com or call 1-800-638-0968.

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