Provider Account Request

Invalid Request, Please Use Request Account Button

Please fill in the fields below to create your account.

Account Information

Required Desired Username

Required Field

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 Field

Required Verify Password

Required Field

Required Email Address

Required Verify Email Address

Time Zone Required

Required Field

User Information

Required First Name

Required Field

Required Last Name

Required Field

Required Phone Number

Required Field

Required Address

Required Field

Required City

Required Field

Required State

Required Field

Required Zip Code

Required Field

Provider Information

Participating With Required

Tax ID / National Provider ID

Required

Press the enter key between ID's

Required Field

Required Full Facility Name

Required Field

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