Provider Registration

Create a login so you can manage your listing after approval.

Your Name *

Your Phone

Email Address (Username) * This will be your username for logging in.

Password * Minimum 8 characters.

Confirm Password *

Practice / Physician Name *

Practice / Group Name Enter the practice or group name if different from the physician name above.

Medical Group If you belong to a medical group, select it here.

Minority-Owned Provider Check if this is a minority-owned practice (Georgia requirement).

Phone Number *

Street Address *

City *

State * Select the state where you primarily practice.

ZIP Code *

Website

Medical Category *

Telehealth services are available

The following fields will be visible for Premium (Tier 2) listings.

Practice Logo Recommended: PNG or JPEG, max 400×200px, under 2MB.

Provider Website Public-facing website displayed on your provider listing.

Provider Description (100 words max)

Designate the primary contact for WC-related inquiries at your practice.

Liaison Name

Liaison Phone

Liaison Email