CREATE YOUR ACCOUNT

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Fill in the information below. Required fields are denoted with an asterisk.

Business Name*

HIPAA Compliant Organization HIPAA Compliance Details

Address*

Address Cont'd

City*

State*

Zip*

Business Phone* xxx-xxx-xxxx

Account Information

First Name*

Last Name*

Your Email Address will be your username.

Email Address*

Confirm Email Address*

Passwords must be at least 8 characters, no more than 15 characters, and must include at least one upper case letter, one lower case letter, and one numeric digit.

Password*

Confirm Password*

The Authorized Agent is the individual registered with the Secretary of State, or who has been deemed responsible for receiving legal correspondence on behalf of the company.

Authorized Agent First Name*

Authorized Agent Last Name*

The Contact Person is any authorized individual within the company that will be the point of contact for any normal business correspondence.

Contact Person First Name*

Contact Person Last Name*

Contact Person Email Address*

Website

Business Fax xxx-xxx-xxxx

EIN # / SSN #

Cost $420.00 Billed Yearly

Coupon Code

VA Tax $ 25.20 (VA Tax Users are charged 6% sales tax.)

Total Due Today $ 445.20

Credit Card Information

First Name on Card*

Last Name on Card*

Credit Card Number*

Expiration Date*

CVV Number*

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