Provider Registration

Please fill out the form below to register with the Delta Health Systems website and to gain access to your patient eligibility, submitted claims and status of benefits. Note: To register on-line you previously must have submitted at least one claim with Delta Health Systems. If you have not submitted at least one claim, then please contact our Helpdesk for assistance with registering at 1-800-422-6099 ext 5699. If there are multiple doctors in your office with different Tax ID numbers, then you will need to register each provider separately to view the provider’s claims information on-line.



I am a

Register as a Provider

First Name: *
Last Name: *
Middle Initial:  
Tax ID: *
 
(Example: 333-12-1234 Exclude any alpha characters.)
   
Doctor or Facility Name: *
Company: *
Title: *
Email Address: *
Bill Address: *
City:  
State:  
ZIP:  
Day Phone: *
Fax:  
 
User ID: *

Password: *
Confirm Password: *
Please select a question and provide an answer. This will be used to reset your password if it is lost.
Question: *  
Answer: *