Self Register

Registration

This registration is for the person at your organization who is responsible for managing all web site (portal) users within your organization. This person is typically a manager. If you are not the person that will manage all the users for your organization, PLEASE DO NOT fill this out. Please have your Office Administrator (OA) for this web site complete this registration form.

If you are a billing company that is not owned by the practice, you will need to have the Office Administrator (OA) at the practice complete this registration form.

Please provide the following information so we can accurately process your registration:

CreateUserViewModel

*All fields are required

Group name:

Your First Name:

Your Last Name:

Your Title:

Phone Number:

Email Address:

Name of Organization:

Tax ID:

National Provider ID (NPI):

Blue KC 8 digit legacy Group #:

(If you do not have a Blue Cross group number, provide the physicians Blue KC 8 digit Legacy provider number in this field)

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