OPIS

Online Provider Information Service

Registration Form

To request an account, please fill out the form below and submit. Please remember your Password, it will not be displayed. You will be sent a confirmation e-mail with an access link. Only claims information related to the Tax ID submitted will be visible to your account. Additional Tax ID's can be added to an account with additional verification after account is active. Once you click on the link in the email your account will be confirmed and you can begin using WebOPIS.

Email (This will also be your user name)

Please enter a valid e-mail.

Confirm Email

Please enter a valid e-mail.

Password (6 or more alphanumeric characters)

Please provide a valid password.

Confirm Password

Please provide a valid password.

First Name

Please provide a valid first name.

Last Name

Please provide a valid last name.

Business Name

Please provide a valid business name.

Address 1

Please provide a valid address.

Address 2 (optional)

Please provide a valid address.

City

Please provide a valid city.

State

Please select a state.

Zip Code

Please provide a valid zip code.

Primary Tax ID

Please provide a valid tax ID.

Physician License (optional)

Please provide a valid physician license.

Phone

Please provide a valid phone number.

Fax (optional)

Please provide a valid fax number.

Extension (optional)

Please provide a valid phone extension.