Request Web Account
If you are a associated with a hospital or ancillary provider please fill out this form.

Please provide the following information to assist us in validating your identity
and establishing your user account (all fields are required).

First Name:
 *      
Last Name:
 * 
Date of Birth:
 * 
 
Primary Office
Address:


 * 
Company Name:
 * 
Contact Phone:
 * 
Email Address:
 * 
Provider Tax ID:
 * 
State Lic. Number:
 * 
Provider Name:
 * 
IPA Affiliation:
 * 

Note:
Additional users can be added after successful login.


I acknowledge and I am requesting electronic access to the Conifer Health Solutions provider portal.

I understand that my access and any staff member's access is a privileged right and I and my staff further understand the legal responsibilities we have to protect the privacy of our patients from unauthorized use of protected health information. We agree to protect our usernames and passwords and will not disclose them to anyone.
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