Health Professional Provider of Service Account Application

*Dental providers are automatically registered, Click here.

 

* indicates a mandatory field
Provider Information
*
*
 
*
*
*
*
*
*
Select your college or association from the drop down menu. If your college or association is not on the list, enter the name in the field below
or
*
Contact Information
*
() -
 
() -
 
() -
*
The Email Address where you wish to receive email correspondence.
*
 
*
Will you be billing on behalf of your clients?
Will you be billing on behalf of your clients?
 
*
Payment direction.
Payment direction.
(only the clinic will have
access to payment details)
    
(only the individual professional
will have access to payment details)
    
providerConnect Secure Services Online Account Information
* - not case sensitive
- min of 8 and max of 20 characters
- combination of alphanumeric characters (a-z|A-Z|0-9)
* - Password minimum length should be between 8 to 32 characters
- A minimum of one upper-case letter
- A minimum of one lower-case letter
- A minimum of one number
- A minimum of one special character ( Allowed characters ~!@$%^&*_-+=`|\(){}[]:;,.?/)    
- Must not contain any blanks or spaces
* - Password minimum length should be between 8 to 32 characters
- A minimum of one upper-case letter
- A minimum of one lower-case letter
- A minimum of one number
- A minimum of one special character ( Allowed characters ~!@$%^&*_-+=`|\(){}[]:;,.?/)    
- Must not contain any blanks or spaces
Note: Best practice for setting the password is to avoid using first & last name of the user.

If you forget your password, you will be asked for the answer to your challenge question. Only the correct answer to your challenge question will reset your password.
* Select a challenge question from the drop down menu that can be used to verify your identity should you forget your password or user name. Make sure to select a challenge question that is easy for you to remember.
* The answer to the Challenge Question must be a minimum of 5 characters and is not case sensitive.
Once your application has been approved, your providerConnect Secure Services online account will be activated. Once processed you will receive an email notifying you of the status of your application.
By completing this application, you are registering with the Participating Carriers/Adjudicators/Third Party Payors outlined in Schedule A within your Agreement.