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Provider Website Registration Form

Completion of this registration form is required for all providers contracted with MBHP. MBHP providers are required to adhere to the policies and procedures outlined in the MBHP Provider Manual. The Provider Manual and Alerts can be found in the Provider Information section of the MBHP website.

User names and passwords allow providers to have access to the MBHP Provider Manual, service authorization information, Alerts, and other password-protected information. It is recommended that providers review the website on a regular basis to obtain news and information regarding policy and procedure changes.

Each facility or individually contracted provider may request multiple accounts by completing this form for each contracted/Medicaid number.

Individual Practitioner, Group, or Facility Name:	Required
Choose one:	Please select an option
Individual Practitioner, Group, or Facility NPI Number:	Required It must be 10 digits
User name: Must be at least 5 - 10 characters in length. Spaces, commas, quotes and underscores are not acceptable.	Required Invalid user name
Password: Must be at least 5 - 10 characters in length and contain at least one letter, one number and one special character (e.g. # @ !). Spaces, commas, quotes and underscores are not acceptable.	Required Invalid password
E-mail address:	Required Invalid Email
Phone number:	Required Invalid phone number Ex:617-495-0086
*Please ensure that the user name and password you create is something you will remember. All passwords should be kept confidential.
Printed Name of Authorizer: Required	12/21/2024