Industrial Accidents Forms Registration Page

Registration Type:

Physician

First Name:
Last Name:
Phone Number:
Address:
City:
State:
Zip:

Registration Email and Password

Email:
Password:

Notes: The email you submit will be used as your registered email and login ID. Password must be at least 8 characters and should contain one number.

Disclaimer and Terms of Use

Treatment administered by a licensed health care provider is defined in the Workers Compensation Act 34A-2-111. By checking this box you verify that you understand and will abide by the requirements outlined therein.

  I have read and agree with the Disclaimer and Terms of Use.

Note: After successfully registering you will be directed to the login page. After you login you will be able to use the online forms.