IMPORTANT NOTICE: By completing this registration form, you are stating that you are a PROVIDER of medical or dental care services. If you are a member of a plan administered by UMR, please go to https://member-fhs.umr.com for access to your claim and benefit information.
All fields are required.
  Enter user information:
First name:
Last name:
Phone number: ( - 
Fax number: ( - 
E-mail address:

  Enter business information:
Business name:
Street address:
City:
State:
Zip code:

  Enter username and password information:
Username:
Usernames must be at least 8 characters long, contain at least one number and one letter and cannot contain the following characters: * % " / ? ! ; : ' &.
Password:
Passwords must be at least 8 characters long, contain at least one number and one letter and are case sensitive.
Re-enter password:
Identifying question 1:
Your answer:
Identifying question 2:
Your answer:

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