New User Registration
*
Required
*
E-Mail
:
We recommend using your email address with out the domain
name,i.e
user@yourdomain.com
would be user.The user name
field will automatically be populated with the first part of
your email address,but may be changed at any time.
*
User Name
:
*
Password
:
*
Confirm Password
:
First Name :
*
Last Name
:
Title :
Department :
*
Phone Number
:
Fax :
*
User Type
:
Provider
Vendor
Facility
*
Company(s)
Available Company(s)
CAPITAL HEALTHCARE PHYSICIANS
CHP
Selected Company(s)
*
Company(s)
:
--Select Company--
CAPITAL HEALTHCARE PHYSICIANS
A
dd
D
e
lete
*
Provider(s)
P
rovider NPI:
Provider
T
ax ID:
Last
N
ame:
F
irst Name:
Sea
r
ch
C
l
ear
Provider Name
Provider ID
Company ID
Provider Name
Provider ID
Company ID
*
Vendor(s)
V
endor ID:
Vendor N
a
me:
Vendor Name
Vendor ID
Company ID
Vendor Name
Vendor ID
Company ID
*
Facility(s)
F
acility ID:
Facility N
a
me:
Facility Name
Facility ID
Company ID
Facility Name
Facility ID
Company ID
Type the letters you see in the below picture
*
Captcha :
S
ubmit Request
C
lear Form
Copyright© 2006-2024 Cedar Gate Technologies. All Rights Reserved. System availability, transaction execution, and response times may vary due To volume, system performance and other factors.Technology provided by Cedar Gate Technologies.
EZ-NET v6.8.0
Please wait...
Please wait...