Provider Registration Help Request a username and password for access to Online Report Distribution Please enter the Provider Name and Address as it is listed in the Provider Directory. * Required field Provider Information: *Provider Name: Provider is required *Address Line 1: Address is required *Primary Medicaid ID: Medicaid is requiredMust be Numeric! Address Line 2: *Telephone: Phone is requiredFormat is not (xxx-xxx-xxxx) *City: City is required *E-Mail: E-mail is requiredE-mail format is not correct *State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY *Fax: Format is not (xxx-xxx-xxxx) *Zip Code: Zip is requiredZip format is not correct *Are you registering for access to Medicaid reports or Charity Care reports? Medicaid Charity Care Access Type is required If you do participate in the Charity Care program, select Charity Care otherwise do nothing. You will be required to have different username and password combinations for your Medicaid and Charity Care reports. To access both Medicaid and Charity Care reports, you must register twice, once for each type of access.