ABE Provider Portal Registration

ABE Provider Portal Registration/Request Details/Follow-up Information

Complete all data fields, incomplete entries will not be approved.

Title

Request Type

User First Name

User Last Name

User Email

User Phone Number

Provider/Organization Information

Information provided must be exact match to information used to obtain ABE User ID.

ABE User ID

Provider Type

Provider ID

Provider Name

Provider Address

Provider City

Provider State

Provider Zip Code

Supervisor Name

Supervisor Phone

Supervisor Email

Attest

I attest that I have been approved by my organization to serve as the Primary ASA and HFS point of contact.