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Details
Information

Please follow below additional instructions while entering information on the Registration form.

  • Street Address:  Enter no more than 100 characters.
  • City                  :  Enter no more than 50 characters.
  • State                :  Please enter 2 letter state abbreviation to represent U.S. States, for all others, enter 'N/A'.
  • Zip Code          :  Must be 5 digit number.

Required items are marked with an asterisk (*).

Name:
*First Name:
*Last Name:
*Email:
  • State Employees, CA-MMIS Contractors, CCS County Staff, DXC Employees and DXC Subcontractors, IBM Employees and IBM Subcontractors : Please use your work email for registration.
  • Must be a valid email address and no more than 100 characters.
*Username:
Username is your email address. Please confirm by re-entering your above email address here.
*Password:
  • Must be at least 8 characters and no more than 25 characters.
  • Cannot contain 'password', '123456', '654321' or contain the username.
  • Must be composed of characters from at least three of the following four groups from the standard keyboard: uppercase, lowercase, numeric, special characters.
Confirm by entering again:
Timezone:
Address:
Street Address:
*City:
*State:
*Zip Code:
*Country:
Phone Number(s):
*Telephone:
*Job Title:
*Department:
*Type of User:
*Primary Claim Type:
  • In which of the following areas are you typically involved?
  • Highlight all that apply using shift or ctrl key.
Credential:
  • Which of the following credentials, if any, do you possess?
  • Check all that apply.
*NPI:
  • Healthcare Providers, Provider Staff or staff working for Healthcare Providers are required to enter a 10-digit National Provider Identifier(NPI).
  • All others, please enter ‘N/A’.
*User Agreement:

This system is for use by authorized users and is subject to being monitored and/or restricted at any time. Unauthorized or improper use of this system may result in administrative disciplinary action and/or civil and criminal penalties. By using this system you indicate your awareness of and explicit consent to these Conditions of Use and Privacy Policy.

 

Check this box to indicate your awareness of and explicit consent to the Conditions of Use and Privacy Policy.

 


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