The Humboldt Independent Practice Association
    2315 Dean Street707.443.4563  Phone
     Eureka, CA 95501707.443.2527  Fax
New User Registration
   
*Required    
  * E-Mail :
  We recommend using your email address  with out the domain
name,i.e user@yourdomain.com  would be user.The user name
field will automatically be populated with the first part of
your email address,but may be changed at any time.
  * User Name :
  * Password :
  * Confirm Password :
     First Name :
  * Last Name :
     Title :
     Department :
  * Phone Number :
     Fax :
  * User Type :
  * Company(s)
  * Company(s) :

  * Provider(s)
Provider NPI: Provider Tax ID:
Last Name: First Name:
         
Type the letters you see in the below picture
* Captcha :
 
 
EZ-NET v6.7.0