New User/Reactivate Account - iConnect Form
Account Type
*
New User Account
Reactivate User Account
If reactivation, previously know User login ID
Name of Facility
*
User Legal Name
*
Legal First Name
Legal Last Name
User Role
*
Provider
Clinical Staff
Front Desk/Administration
Provider Legal Name
*
Legal First Name
Legal Last Name
Provider Credentials
*
Provider Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Provider Facility Phone Number
*
-
Area Code
Phone Number
Provider Facility Fax Number
*
-
Area Code
Phone Number
Provider NPI
*
User Email
*
example@example.com
Sponsor Legal Name
*
Legal First Name
Legal Last Name
Sponsor Contact Number
*
-
Area Code
Phone Number
Sponsor Email
*
example@example.com
File upload
*
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of
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