Self Service - Registration & Management

By completing this information, you are certifying that you work directly for the Provider and are not a third-party biller or vendor.
Please note that this process will only result in a new user being created for an existing EDISS Connect account and not the creation of a new EDISS Connect account.

Please enter the following details belonging to your account to add a new user:

Please enter a 10-digit NPI* :

Submitter ID* :

TAX ID (SSN)* :

First Name* :

Last Name* :

Username* :

Email* :

Email Confirm* :

Text Verification Required