Portal Access Request

Portal Log-In Enrollment Request

Ph: 1-888-626-5246 Fx: 1-888-626-5731
Enrollment: Our team will contact your office to verify this request and then send you an email to complete the enrollment. You will then have access to our portal, which allows you to monitor the status of prescriptions, send/receive messages to our team and upload/download documents.

Staff Access: We can group individual provider profiles together to allow a single user to access the portal for all providers in their practice. Add all providers to your group.
Request Type*

Start New ProfileEdit Existing Profile
Practice Information
Practice Name
Street Address

Suite

CityState / Province

Postal / Zip Code
*
Practice Phone Number.
*
Practice Fax Number.
Profile Type*

ProviderStaffAdd AccessRemove Access
Your Name*
Your Title*
Your Email*
Practice Email
Staff to add/remove:
Staff name
Staff email

Providers to add/remove

Portal Log-In Enrollment Request