Request Web Account
CapConnect Registration Instructions

Please provide the following information to assist us in validating your identity
and establishing your user account (all fields are required).

First Name:
 * 
Last Name:
 * 
Primary Office
Address:


 * 
Company Name:
 * 
Contact Phone:
 * 
Email Address:
 * 
State Lic. Number:
 * 
IPA / Hospital / Health Plan
Affiliation(s):
 *
Provider Tax ID:  * 
Provider Name(s):
Provider Name Include
No providers available for the taxId entered and affiliated IPA / Hospital / Health Plan selected.
Contracted Provider:

Note: Only contracted providers will be able to add additional users after successful login.


I acknowledge and I am requesting electronic access to the Conifer Health Solutions provider portal.

I understand that my access and any staff member's access is a privileged right and I and my staff further understand the legal responsibilities we have to protect the privacy of our patients from unauthorized use of protected health information. We agree to protect our usernames and passwords and will not disclose them to anyone.
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