Health Care Provider Registration

This form is for health care providers only.  Please fill out this form, fax or attach your license, and we will contact you.  If you have questions, call us at 1-877-303-3238 or 1-650-323-3238.

  • Upload a PDF or image of your license (photos accepted) OR fax a copy of your license to: (650) 887-0313.
    Accepted file types: pdf, jpg, jpeg, gif, png, tiff, bmp.