An official website of the United States government
This page displays when you select the Representative account type. You are asked to submit information for the representative that will be submitting cases under this WCMSAP Account. A Social Security Number (SSN) or Health Insurance Claim Number (HICN) cannot be registered more than once.
Fields marked with an asterisk * are required.
| First Name | Enter the representative’s first name. |
| MI | Enter the representative’s middle initial. Optional. |
| Last Name | Enter the representative’s last name. |
| Social Security Number | Enter the representative’s social security number. |
| E-mail Address | Enter the electronic mail address used by the representative for work-related e-mail. |
| Re-enter E-mail Address | Enter the E-mail address a second time for verification purposes. You must type the E-mail address each time. You may not cut and paste. |
| Phone | Telephone number where the representative can be reached. The extension field is optional. |
| Fax | Facsimile number used by the representative. Optional. |
| Address Line 1 | Enter the first line of the representative’s mailing address. |
| Address Line 2 | Enter the second line of the representative’s mailing address. Optional. |
| City | Enter the city where the representative is located. |
| State | Select the representative’s state from the dropdown list. |
| Zip Code | Enter the representative’s 5-digit zip code. The Zip+4 field is optional. |
After you have correctly entered all representative information, click the Next button to proceed to the next page in the New Registration step.
Click the Previous button to return to the previous page.
Click the Cancel button to return to the WCMSAP Welcome 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