::: AHG Registration Page :::

Your Account Details

Email Address *
Your First Name *
Your Middle Name
Your Last Name *
Complete the form either as a Provider (Doctor, Therapist, etc.) or a Facility (Hospital, Free Standing Clinic,etc.). You may complete for both if it applies to you. Failure to enter all relevant data as either a Provider or a Facility will delay receiving user credentials.
Provider Name
Provider Tax ID
Provider NPI at present location
Provider Street
Provider Address 2
Provider City
Provider State
Provider Zip Code
Provider Telephone
Provider Fax

Facility Name
Facility Tax ID
Facility NPI at present location
Facility Street
Facility Address 2
Facility City
Facility State
Facility Zip Code
Facility Telephone
Facility Fax

I accept the terms of the Business Associate Agreement with American Health Group, Inc.