External Provider Registration – Houston Neuropsychology Associates

Welcome! We are pleased to offer our referring healthcare providers secure and easy access to our reports on their patients. To request access to our secure report vault, please complete the following registration form.

Healthcare Provider's Name(Required)

Please enter the name of the healthcare provider (e.g., doctor) requesting access to our secure report vault.

First Last

Name of Person Registering

If you are registering on behalf of the healthcare provider listed above, please enter your name.

First Last

Kelsey-Seybold Employee?

Please check the following box if you are a Kelsey-Seybold employee. Otherwise, leave it it blank.

Yes, I am a Kelsey-Seybold Employee.

Phone Number(Required)

Please provide a phone number at which we may reach you if needed (e.g., to verify your identity).

Email Address(Required)

Enter Email Confirm Email

Username(Required)

Please select a username for this site (letters and numbers only, please).

Password(Required)

Enter Password Confirm Password

Hidden

Password Copy

Terms and Conditions(Required)

By registering for an account, I attest that I am or have the authority to represent the above-named healthcare provider. I agree to keep my login information secure and not to share it with others. I accept that it is my responsibility to inform HNA of any changes needed to my access (such as due to staff changes or turnover). Finally, I acknowledge that HNA will no longer fax reports to me and that all reports will be published through this website.

Yes, I agree to these terms.

Name

This field is for validation purposes and should be left unchanged.