HealthTrio connect - Provider Registration - User Information

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As the primary registrant, you are automatically a local admin

First Name Please enter your first name
Middle Initial
Last Name Please enter your last name
Title
E-Mail Please enter a valid email address
Confirm E-Mail
Office Phone Please enter a valid phone number Example: (555) 555-5555
Extension # Please enter a valid phone number Example: 123456
Office Fax Please enter a valid fax number Example: (555) 555-5555
Clinician Check this box if you are a clinician
User Name Please enter a value for user name
Password Please enter a value for password
Password must contain at least 10 character(s).

Password cannot contain your user name.

Password cannot contain your First or Last Name.

You cannot re-use passwords previously used.

Password must contain at least 1 number(s).

Password must contain at least 1 special character(s).

Password must be mixed case.
Confirm Password
Security Question 1
Security Answer 1 Your answer may not contain your username.
Security Question 2
Security Answer 2 Your answer may not contain your username.
Security Question 3
Security Answer 3 Your answer may not contain your username.

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