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)