TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. • HF0619x023 (08/19)
A Wholly-Owned Subsidiary of Centene Corporation
Please complete all sections and submit via fax to 1-844-787-9889.
Section I: General Information (All elds must be completed)
First Name: Last Name:
Business Phone: Business Email:
Title: Department:
Supervisor Name: Preferred Username*:
Section III: Billing Company Applicants
If you work for a billing company, complete the following:
Company Name: Billing Address:
City: State: ZIP Code: Billing Phone:
Signature: Date:
Section II: Verication Point of Contact Information (All elds must be completed)
We may reach out to this point of contact to verify the applicant’s information.
First Name: Last Name: Title:
Business Phone: Business Email: Department:
Practice Information (All elds must be completed)
Please only register one time. You can add additional Tax IDs once your account has been created.
Primary Tax ID: Practice NPI: Practice Name:
Practice Address: City: State: ZIP Code:
* Must contain a minimum of 8 characters and a maximum of 20 characters.
* May contain special characters, but the # sign is not allowed.
* If the username is taken, Health Net Federal Services, LLC (HNFS) may add additional characters to complete the registration process.
Provider agrees that all health information, including that related to patient conditions and medical utilization available
through the portal or any other means will be used exclusively for patient care and other related purposes, only as permitted
by the HIPAA Privacy Rule or other more stringent applicable regulations. Registration is for an individual person. Sharing of
usernames/passwords is not permitted.
Please allow HNFS up to 10 business days to process this request. We will send a conrmation email once we have veried
your information and created your account. Once received, you must log in at within 60 days to
activate the account.
Provider Registration Form
Verify you have completed all required elds above, and sign and date prior to submitting to HNFS.