Registration

This site does not collect personally identifiable information (PII). Please use only your work email, work phone number, etc. when creating your login information for this site.

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User Information

User Name:

Password

Confirm Password:

Security Question

Security Answer:

Title:

Salutation:

First Name:

Middle Name:

Last Name:

Business Contact Information

Email:

Confirm Email:

Phone: (xxx xxx xxxx)

Fax: (xxx xxx xxxx)

Business Physical Location Address

Street Address 1:

Street Address 2:

City:

State:

Zip: (xxxxx xxxx)

Business Mailing Address

Same as Business Physical Address:

YesNo

Street Address 1:

Street Address 2:

City:

State:

Zip: (xxxxx xxxx)

Request User Account Role

Account Role:

Upload Admin

Users who are assigned to the Upload Admin role can upload and edit data submission files for their state, create or remove an organization, manage an organization profile, manage their personal profile, edit summary of benefits information, edit program/health plan name combinations, and certify data.

Uploader

User who are assigned to the Uploader role can upload and edit data submission files for their state, and manage their personal profile.

Submitting Dental Provider Data For

Program Type:

State:

Organization

Organization:

Note: If you do not see your organization listed and would like to request to have your organization added, please contact your state administrator or IKNTechnicalHelp@hrsa.gov

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