Create your account. BHSD Roster Credentials Does your agency currently have login credentials to this portal? No Yes Agency Information Agency/Provider Organization * Only a-z and A-Z and 1-9 and .-&, and (space) are allowed Is the Agency Mailing address the same as the Physical address? No Yes Administrative Physical Address * Administrative Physical Address Administrative Physical Address Administrative Physical Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Administrative Mailing Address * Administrative Mailing Address Administrative Mailing Address Administrative Mailing Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Primary Contact First Name * Primary Contact Last Name * Job Title * Clinical Director Clinical Supervisor CEO Office Manager Executive Director Billing Specialist Financial Officer OtherOther Section Primary Contact Email * Confirm Primary Contact Email * Section Primary Contact Phone * Agency Type * BHA 432 (Behavioral Health Agency) OTP 343 (Opioid Treatment Program) Other Agency Medicaid Enrollment ID (if available) Agency Group NPI (if available) Credentialing Access Please identify the ONE person who is tasked with credentialing for your organization. There is only ONE email associated with your roster updates for security purposes. First Name Last Name Email (is used as login name, too) Confirm Email (is used as login name, too) Create your Password and confirm it. * cancel1 check1 Eight characters minimum cancel1 check1 One lowercase letter cancel1 check1 One uppercase letter cancel1 check1 One number cancel1 check1 One special character Confirm Create your Password and confirm it. * CAPTCHA You can use your Agency's credentials to login. Please click Here to log in. Lookup If you are human, leave this field blank. Register
