Create enrollment credentials

Create your username

Enter a username you want to use when you login. Asterisk (*) denotes required field.
Create your username
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Username must be between 6 and 50 characters which may be a combination of letters, numbers and #special characters# and is case sensitive.

Create your password

Enter a password you want to use when you login. Asterisk (*) denotes required field.
Create your password
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Password must be between 8 and 50 characters with no spaces, must include at least one numeric digit, is case sensitive, and can be a combination of letters and #special characters#.
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Create your login security authorization

Choose a login security question and enter your answer. This question will be used as part of the login authorization process. You will be prompted to enter the answer for your selected question when you try to login to your account. Asterisk (*) denotes required field.
Create your login security authorization
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Create your password recovery credentials

Create a forgotten password question and enter the answer. This question will be used in the password reset process. You will be prompted to enter the answer for this question in case you need to reset your password in the future. Asterisk (*) denotes required field.
Create your password recovery credentials
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FRAUD WARNING

Any person who knowingly with the intent to defraud any medical agency by concealing and filing false information for medical care or treatment may be found to have committed a fraudulent act which is a crime and may be subject to criminal and civil penalties.