To register as a user of the AFMC web portal, please complete the form below.

Once we receive your registration, you will receive an email confirmation asking you to verify your email address. Please complete the registration process in order to receive your User ID and temporary password.

User Details

Provider Details

Mailing Address

(Location where services are rendered)

To register as a user of the AFMC web portal, please complete the form below. Once we receive your registration, you will receive an email confirmation asking you to verify your email address. Please complete the registration process in order to receive your User ID and temporary password.

User Details

*First Name
*Last Name
Credentials (RN, LPN, MD, etc.)
*Email Address
*Phone Number
*Fax Number
Provider Details

*Provider / Office / Group Name
Specialty
*NPI
*Medicaid ID
Group Number
Submitting Provider(s) List
Mailing Address (Location where services are rendered)

*Street
*City
*State
*Zip/Postal Code