External Provider Registration

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.
Name of Person Registering
If you are registering on behalf of the healthcare provider listed above, please enter your name.
Kelsey-Seybold Employee?
Please check the following box if you are a Kelsey-Seybold employee. Otherwise, leave it it blank.
Please provide a phone number at which we may reach you if needed (e.g., to verify your identity).
Email Address(Required)
Please select a username for this site (letters and numbers only, please).
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.
This field is for validation purposes and should be left unchanged.