Health PAS-OnLine Registration

Step:Demographic Information

* Indicates required field.

Register As :

select

*Name :

*First Name

M.I.

*Last Name

Title

select

Company Name :

ZIP code must be in xxxxx or xxxxx-xxxx for USA and AXA XAX for Canada. Where A is any uppercase alphabetic character and X is a numeric digit from 0 to 9.

*ZIP :

*Address 1 :

Address 2 :

*City :

*State/Province :

select

Country :

select

*Telephone :

Website Address :

Enter the following credentials for any of your provider billing records.
If you have more than one billing provider record, you may add the additional provider records
to your online account after registration.
Enter values for FEIN/SSN; either NPI or Atypical ID; and PIN.
For providers, these values are your tax ID, NPI or API, and PIN.
For Billing Agents, these values are for a provider for whom you intend to submit transactions.

*FEIN/SSN :

NPI :

Atypical ID :

*PIN :

Step:Security Information

* Indicates required field.
* User Name :
	Password must contain at least 8 characters consisting of an upper and lower case letter, a special character such as a # or * or ^ (except ,) and a number.
* Password :
*Re-enter Password :
* Email Address :
*Re-enter Email Address :

Step:Security Questions and Answers

* Indicates required field.

In case you forget your password.....
Please set your security questions and answers, so you will be able to reset your password.
Answers are not case sensitive. Answers with or without capitalization are okay. Remember to create answers that are unique so you'll remember them.
Special characters are not allowed.
Answer must contain at least 4 characters.
All fields are required.

* Your first question :

select

* Answer :

* Your Second question :

select

* Answer :

* Your third question :

select

* Answer :

Step:Confirm Information

Step:Agreement

Yes, I agree to the above terms and conditions.			Print
* Signature :	Please enter the same First Name and Last Name as entered in Demographics Information. ({0} {1})	Date :
Host Name :	N/A	IP Address :	10.129.230.190