CareFirst Registration
6:58 PM, November 20, 2009
CareFirst Registration
:
* indicates a required field
* Are you a participating provider
with CareFirst?
No
Yes
* Please choose a plan:
MD/DC
DE
* Are you a Billing Agency?
No
Yes
* Name of Organization:
* Organization Tax ID:
(9 digit Federal assigned number)
* Proprietor Name:
(Name of owner of provider organization)
* Address 1:
Address 2:
* City:
* State:
--Please Choose--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
* Zip:
-
00000 or 00000 -1234
Business Contact:
* First Name:
* Last Name:
Title:
* Phone:
x
* E-mail Address:
* Confirm E-mail Address:
Fax:
User Registration:
The Primary User will become a Delegated Administrator
* Primary User First Name:
* Primary User Last Name:
* Choose an authentication number:
(like the last 5 digits of your telephone number)
This number will be used to identify you to our help desk if you need to have your password reset.
Additional User 2?
No
Yes
* Is this user a Delegated Administrator?
No
Yes
* User 2 First Name:
* User 2 Last Name:
* Choose an authentication number:
(like the last 5 digits of your telephone number)
This number will be used to identify you to our help desk if you need to have your password reset.
Additional User 3?
No
Yes
* Is this user a Delegated Administrator?
No
Yes
* User 3 First Name:
* User 3 Last Name:
* Choose an authentication number:
(like the last 5 digits of your telephone number)
This number will be used to identify you to our help desk if you need to have your password reset.
Additional User 4?
No
Yes
* Is this user a Delegated Administrator?
No
Yes
* User 4 First Name:
* User 4 Last Name:
* Choose an authentication number:
(like the last 5 digits of your telephone number)
This number will be used to identify you to our help desk if you need to have your password reset.
Terms of Use:
CareFirst Direct is for contracted providers and their staffs only. Through this registration, you agree that your organization is a contracted provider and that the same terms outlined in your contract related to patient confidentiality, privacy and business practices also apply to all information found on CareFirst Direct.
I accept the terms of use
