An official website of the United States government
This page asks you to enter your personal information.
Required fields are noted by an asterisk *.
| First Name | Enter your first name. |
| MI | Enter your middle initial. Optional. |
| Last Name | Enter your last name. |
| E-mail Address | This field is pre-populated with the E-mail address you provided on the previous page. |
| Phone | Enter your company or work telephone number. The extension field is optional. |
| Address Line 1 | Enter the first line of your mailing address. |
| Address Line 2 | Enter the second line of your mailing address. Optional. |
| City | Enter your city. |
| State | Select your state from the dropdown list. |
| Zip Code | Enter your zip code. The ZIP+4 field is optional. |
If you have correctly entered all your personal information as the Account Designee, click the Next button to proceed to the next page in the Registration process.
Click the Previous button to return to the previous page.
A federal government website managed and paid for by the U.S. Centers for Medicare and Medicaid Services.
7500 Security Boulevard, Baltimore, MD 21244