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Register New User - Practitioner

Enter ALL of the following to enroll:

ID Number:
Your Provider License #

First Name:

Last Name:

Benefit Type:
eg. Dental

eg. Denturist

Postal Code(s):
Enter Postal Code(s) of desired Billing address(es) to administer. Do not use dashes or spaces. eg. T7Z1X5

EMail Address:
Used to send your password.

Desired Password:
Do not use dashes or spaces - 6 or more alpha/numeric characters only

Re-enter Password:
Re-enter same password to verify

Security Question:
eg. What is my favourite pet's name?

Security Question Answer:
eg. Spot